i?'      THE       > 
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O 


HEALTH 


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A  TEXT-BOOK 


OP 


UROLOGY 


MEN,  WOMEN  AND  CHILDREN, 

f 

INCLUDING  UEINARY  AND  SEXUAL  INFECTIONS 
UEETHROSCOPY  AND  CYSTOSCOPY 


BY 

VICTOR  COX  PEDERSEN,  A.M.,  M.D.,  F.A.C.S. 

MAJOR,  MEDICAL  CORPS,  UNITED  STATES  ARMY;  CONSULTING  PHYSICIAN  TO  THE  SELECTIVE 

SERVICE  HEADQUARTERS  IN  THE  CITY  OF  NEW  YORK;  MEMBER  OF  THE  COUNCIL  OF 

NATIONAL  DEFENCE,   NEW  YORK  STATE   COMMITTEE,   MEDICAL  SECTION; 

VISITING  UROLOGIST  TO  ST.  MARK's  HOSPITAL;  MAJOR,  MEDICAL 

RESERVE  CORPS,  UNITED  STATES  OF  AMERICA. 

MEMBER    OF    THE    AMERICAN    UROLOGICAL   ASSOCIATION,    AMERICAN    MEDICAL    ASSOCIATION, 

NEW    YORK     STATE     AND     COUNTY    MEDICAL     SOCIETIES,    NEW    YORK    ACADEMY    OF 

MEDICINE,    AMERICAN    ELECTROTHERAPEUTIC   ASSOCIATION,    THE  ASSOCIATION 

OF  MILITARY  SURGEONS  OF  THE  UNITED  STATES,  AND  OF  THE  COMMITTEE 

ON    VENEREAL    DISEASES    OF    THE    ADVISORY    COUNCIL  OF    THE 

DEPARTMENT    OF    HEALTH    OF   NEW   YORK   CITY 


ILLUSTRATED  WITH  362  ENGRAVINGS,  OF  WHICH  152  ARE  ORIGINAL 
AND  13  COLORED  PLATES 


LEA   &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1919 


Copyright 

LEA  &  FEBIGER 

1919 


61 


IN  MEMORY 
OF 

WILLIAM  WALTER  GENGE,  M.D.,  CM. 

WHO 

AMID   THE   DIFFICULTIES   AND   TRIALS   OF   PRACTICE 

IN   THE    GREEN   MOUNTAINS   OF  VERMONT 

FIRST   TAUGHT   THE    INSPIRATION   AND   BLESSING    IN   A 

LIFE   SPENT   IN   THE   SERVICE    OF  MANKIND 


AND 


IN  GRATITUDE 
TO 

WALTER  BROOKS  BROUNER,  A.B.,  M.D. 

WHO 

THROUGH  A  HUMAN  GENERATION 

HAS  SHOWN  A 

PERSONAL  AND   PROFESSIONAL  FRIENDSHIP  WHICH 

HAS   NEVER   FALTERED   NOR   FAILED, 

THIS   BOOK 

IS   SINCERELY   DEDICATED 


PKEFACE. 


In  preparing  a  text-book  on  any  branch  of  medicine  originality, 
except  perhaps  in  arrangement,  is  ahnost  impossible. 

The  present  work  is  planned  on  a  rather  uniform  discussion  of  the 
clinical  side  of  the  diseases  included,  for  the  benefit  of  students  and 
general  practitioners,  who,  in  not  being  widely  familiar  with  the  sub- 
jects, will  be  served  by  a  fixed  view-point.  The  reader  will  perceive 
this  outline  in  such  subjects  as  etiology,  pathology,  symptoms,  diag- 
nosis and  treatment.  A  further  advantage  of  this  method  is  that  these 
five  subjects  are  correlated  unmistakably  by  it — a  fact  which  also  assists 
the  student. 

The  disadvantage  of  fixed  structure  is  a  varying  amount  of  similarity 
of  style  in  passing  from  one  disease  to  another  or  from  one  chapter  to 
the  next,  but  the  effort  has  been  made  to  correct  this  disadvantage  by 
variations  in  diction. 

The  usual  paragraphs  on  course  and  prognosis  have  been  omitted  as 
separate  subjects  but  have  been  carefully  embodied  in  symptomatology 
as  parts  of  "termination"  of  each  disease.  The  stages  of  incubation, 
invasion,  establishment  and  termination  are  described  so  that  the 
student  receives  a  word-picture  of  the  important  affections  and  learns 
the  course  and  prognosis  not  as  afterthoughts,  but  as  integral  elements 
of  the  various  cases.  For  the  same  reason,  complications  are  mentioned 
during  "  termination"  of  the  primary  disease.  The  complications  have, 
however,  individual  portions  of  the  text  because  in  turn  their  stages  of 
development,  progress  and  cessation  are  detailed. 

Under  diagnosis  in  the  subject  of  functional  test  of  the  kidneys, 
hematology  has  been  included  as  one  of  the  latest  additions  to  oiu* 
knowledge  and  as  one  of  the  most  accurate  methods.  Authorities  are 
quoted  as  to  the  normal  range  of  urea,  uric  acid,  creatinin,  sugar, 
cholesterin  and  urinary  salts,  and  also  as  to  pathological  proportions 
and  their  causes.    Doubts  as  to  values  are  clearly  verified  and  explamed. 

Physical  treatment  is  certainly  in  the  ascendant.  The  next  genera- 
tion will  see  it  more  and  more  amplified,  not  to  supplant  but  to  augment 


VI  PREFACE 

other  metliods.  A  familiar  example  is  the  use  of  Roentgen  rays  and 
radiimv,  and  less  usual  at  present  are  hydrotherapy,  heliotherapy  and 
electrotherapy.  In  human  nature  the  average  eriticism  is  adverse  and 
destructive,  while  relati\ely  few  are  favorable  and  constructive.  Nearly 
e\-ery  urologist  who  discourages  physical  treatment  is  not  possessed 
of  the  necessary  apparatus,  and  therefore  cannot  say  from  his  owi\ 
experience  more  than  that  he  obtains  good  results  from  other  methods. 
The  ^^'riter  is  not  content  and  believes  that  the  profession  should  not 
be  satisfied  with  nonconunittal  inexi)erience.  He  therefore  deter- 
mined to  ha\e  jjhysical  treatment  well  discussed  in  his  work,  and  is 
indebted  to  Dr.  Edward  C.  Titus,  one  of  the  well-known  American 
authorities,  for  suggestions  and  additions.  Those  who  have  not  tried 
physical  methods  are  thus  aided  to  do  so  in  good  faith  and  with  encour- 
agement, because  when  compared  with  drugs  and  chemical  methods, 
their  action  is  far  more  definite  and  more  under  control  of  the  physi- 
cian at  all  times. 

The  data  on  physical  treatment  comprise  hydrotherapy,  heliotherapy 
and  electrotherapy.  It  has  been  the  design  to  outline  proper  cases  for 
one  or  all  these  methods,  the  suitable  machine  and  instruments,  the 
type  of  application,  the  strength  of  application  and  the  duration  and 
frequency  of  the  treatment.  To  these  facts  have  been  added  aftercare 
and  adjuvants.  In  this  way  a  reliable  foundation  has  been  given  to  the 
student  and  the  practitioner  for  the  judicious  and  comprehensive  treat- 
ment by  these  methods  of  cases  properly  selected. 

Under  the  heading  of  treatment,  aftertreatment  is  carefully  con- 
sidered, because  the  average  student  learns  little  of  it  and  general 
practitioners  neglect  aftertreatment  in  whole  or  in  part.  This  subject 
is  subdivided  into  hnmediate  aftertreatment,  comprised  chiefly  in  bed 
care;  and  remote  aftertreatment,  which  is  provided  mainly  by  atten- 
tion in  the  office.  It  is  felt  that  these  principles  of  following  cases 
for  long  periods  after  immediate  discharge  will  result  in  a  far  higher 
percentage  of  complete  cures  and  a  larger  average  of  cures  without 
relapses  and  without  sequels. 

In  separate  paragraphs  in  all  diseases,  the  standard  of  cure  is 
briefly  stated,  so  that  the  student  and  the  general  practitioner  will 
understand  exactly  what  degree  of  relief  should  be  reached  before 
the  patient  is  discharged  from  treatment.  So  far  as  the  author 
knows,  such  brief  discussions  of  the  standard  of  cure  do  not  occur 
in  any  other  work. 

In  order  to  do  justice  to  other  authorities,  every  quotation  and 


PREFACE  Vll 

illustration  is  accompanied  by  a  verified  reference  in  literature.  For 
the  detail  of  these  verifications,  the  author  is  indebted  to  Dr.  Edward 
Preble. 

Nearly  all  the  a>ray  work  of  this  volume  has  been  executed  by  Dr. 
Byron  C.  Darling,  to  whom  great  appreciation  is  hereby  offered. 

The  writer  is  personally  indebted  for  advice  and  encouragement  to 
his  life-long  friend.  Dr.  Walter  B.  Brouner,  and  to  his  associates  in 
St.  Mark's  Hospital,  Dr.  Benjamin  T.  Tilton  and  Dr.  Charles  R.  L. 
Putnam,  and  particularly  among  the  members  of  his  own  staff,  to  Dr. 
Alexander  Alexion  and  to  the  late  Dr.  Joseph  Kaufman.  Numerous 
friends  have  loaned  illustrations  and  notes  of  cases,  for  which  credit 
has  been  given  in  the  text  and  for  which  gratitude  is  now  extended. 

This  book  represents  the  experience  of  many  years  in  urological 
departments  in  New  York  City,  in  private  practice  and  in  the  author's 
clinic  at  St.  Mark's  Hospital.  The  actual  production  of  the  manuscript 
and  illustrations  required  four  years  of  consistent  and  concentrated 
effort.  If  the  outcome  has  become  a  serviceable  and  accurate  book,  the 
time  and  energy  thus  expended  will  be  more  than  amply  repaid. 

V.  C.  P. 

45  West  Ninth  Street, 
New  York  City. 


CONTENTS. 


CHAPTER  I. 

Acute  Urethritis 17 

CHAPTER  II. 

Complications  and  Sequels  op  Acute  Urethritis 82 

CHAPTER  III. 

Complications  and  Sequels  of  Acute  Urethritis  (Continued)     .      .      .     201 

CHAPTER  IV. 
Chronic  Urethritis 263 

CHAPTER  V. 

COMPIJCATIONS  AND  SeQUELS  OF  ChRONIC  URETHRITIS 307 

CHAPTER  VI. 

Complications  and  Sequels  of  Chronic  Urethritis  (Continued)  .      .     334 

CHAPTER  VII. 

Treatment  of  Stricture  of  the  Urethra.    Complications  of  Stricture. 

Urethral  Infections  in  Childhood  and  Old  Age 358 

CHAPTER  VIII. 

General  Principles  of  Diagnosis 428 

CHAPTER  IX. 
General  Principles  of  Treatment 483 

CHAPTER  X. 

Gonococcal  Infection  in  the  Female 524 

CHAPTER  XI. 

Complications,  Sequels  and  R.are  Forms  of  Gonococcal  Infection  in 

THE  Female 597 


X  CONTENTS 

CHAPTEH    XII. 
Urethroscopy     616 

CHAPTER   Xlll. 
Cystoscopy 682 

CHAPTER   XIV. 
Thk  Bl.\ddku 740 

CHAPTER   XV. 
The  Ureters  .\nd  Renal  Functional  Test.s 812 

CHAPTER  XVI. 

Acute  and  Chronic  Suppurative  Inflammations  of  the  Renal  Pelvis 

AND  Parenchyma 868 

CHAPTER  XVII. 
Diseases  of  the  Prostate 943 


A  TEXT-BOOK  OF  UROLOGY. 


CHAPTER  I. 
ACUTE  URETHRITIS. 

Anatomy. — Importance. — In  a  work  on  the  clinical  features  and 
treatment  of  disease  detailed  anatomy  can  have  no  place.  The  reader 
is  therefore  referred  to  works  on  gross  anatomy  and  on  normal  and 
pathological  minute  anatomy.  The  basic  principle  must  never  be 
forgotten  in  dealing  with  infections  of  the  sexual  and  urinary  systems 
that  there  exists  continuity  of  all  the  organs  of  both  systems  through 
continuity  of  their  mucous  membrane  linings.  This  relation  exists 
between  the  organs  of  each  system  in  itself  and  between  the  organs  of 
both  systems  in  their  correlation. 

Gross  Anatomy. — In  the  urinary  system  are  the  excretory  centers  in 
the  kidneys  and  a  continuous  passage  from  the  pelvis  to  the  meatus 
varied  in  caliber  according  to  function.  Dilatation  for  collection  is  seen 
in  the  renal  pelvis  and  the  urinary  bladder  and  more  or  less  cylindrical 
reduction  for  transmission  is  evident  in  the  ureters  and  urethra.  In 
the  sexual  system  the  secretory  glands  are  the  testes  and  may  be 
regarded  as  possessing  continuous  canals  from  the  epidid^mies  to  the 
meatus.  The  function  varies  with  the  caliber.  Collection  is  slightly 
provided  for  in  the  epididymes  and  ampullse  of  the  vasa  deferentia  and 
freely  in  the  seminal  vesicles.  Evacuation  is  procured  between  these 
points  by  the  vasa  deferentia,  ejaculatory  ducts  and  urethra.  This 
urinary  and  sexual  correlation  is  shown  in  Fig.  1. 

Minute  Anatomy. — The  chief  fact  is  the  universal  lining  of  mucous 
membrane,  closely  allied  in  structure  from  organ  to  organ.  The  epithe- 
lium varies  with  function.  As  in  all  other  mucosae,  those  of  the  urinary 
and  sexual  systems  are  highly  vulnerable  to  infection,  have  relatively 
low  resistance  and  recuperation  and  a  distinct  tendency  to  chronic 
inflammation  with  temporary  or  permanent  damage  shown  by  epithe- 
lial substitution  in  mild  cases  and  scar  tissue  replacement  in  severe 
cases. 

Definition  and  General  Principles. — Inflammation  of  the  urethra  at 
any  point  and  due  to  any  cause  may  properly  be  described  as  urethritis. 
The  general  clinical  features  and  treatment  of  urethritis  are  closely 
analogous  among  the  usual  varieties  of  the  disease.  It  is  therefore  well 
to  fix  a  general  conception  of  the  condition  and  then  to  distinguish  each 
important  kind,  especially  in  the  symptoms,  diagnosis  and  treatment. 


IS 


ACUTE  URETHRITIS 


Varieties. — ^'al•ieties  of  urethritis  are  recognized  in  accordance  with 
course,  extent  and  cause. 

1.  ,1*  to  oiisei  and  course:  acute,  subacute  and  chronic,  relapsing, 
coni])lic'Mted  and  unc(>ni])licatetl;  also  ])riinary  as  a  fresh  infection  and 
secondary  as  a  consecjuence  of  preceding  attacks,  or  of*a  systemic 
disease. 

2.  As  to  location  and  extension:  anterior,  posterior,  anteroposterior 
or  general,  and  localized. 

3.  As  to  cause:  nonbacterial  and  bacterial.  The  nonbacterial 
forms  have  no  microorganisms  as  conspicuous  elements,  and  include 
tramnatic,  diathetic  and  eruptive  urethritis.  The  bacterial  forms 
ahvays  \mxe  microorganisms  as  the  primary  exciting  factors  and 
embrace  specific  or  gonococcal  urethritis  and  nonspecific  or  non- 
gonococcal urethritis  under  which  are  classed  catarrhal,  chancrous  or 
syphilitic,  chancroidal  and  herpetic  infections  of  the  urethra. 


AMPULLA 

OF  VAS 

DEFERENS 


VAS 
DEFERENS 

EJACULATORY 
DUCT 
PROSTAT 
UTRI 
PR 


PERITONEUM 


CORPUS 
SPONGIOSUM 


CORPUS 
CAVERNOSUM 


HYDATID   OF 
MORGAGNI 


Fig.  1. — Diagrammatic  representation  of  the  male  organs  of  reproduction  and  their 
relations  to  the  bladder  and  the  urethra.     Lateral  view.     (Toldt.') 

For  general  purj)oses  the  most  important  cUnical  class  if  cation  is 
iccording  to  course,  into  acute  and  chronic  urethritis,  as  all  the  other 
varieties'may  be  brought  under  these  two  headings.  Chronic  urethritis 
is  so  extensive  a  subject  that  it  is  treated  separately  in  subsequent 
cha])ters. 

Location  and  Extension. — Location  and  extension  of  acnte  urethritis 
are,  at  tiie  onset,  at  almost  any  ]K)int  of  the  urethra,  according  to  the 


*  Gray's  Anatomj-,  Philadelphia,  Lea  &  Febiger,  1913. 


ETIOLOGY  IN  GENERAL  19 

cause,  although  most  urethritis  begins  at  the  meatus  because  sexually 
infected.  Anterior  urethritis  extends  anatomically  from  the  meatus  to 
the  triangular  ligament,  while  jjosterior  urethritis  ])asses  from  the 
triangular  ligament  to  the  cutoff  muscle.  Both  are  simply  descriptive 
terms  in  recognition  of  anatomical  subdivisions.  Primary  nongono- 
coccal acute  urethritis,  sexually  acquired,  follows  much  the  same  rule 
as  in  chancrous,  chancroidal,  catarrhal  and  pyogenic  urethritis;  but 
if  asexually  acquired,  it  may  begin  at  any  point  as  in  the  gouty,  rheu- 
matic, lithemic  and  exanthematous  types.  This  variety  is,  therefore, 
as  a  rule,  at  first  either  anterior  or  posterior,  extending  to  involve  more 
and  more  of  the  canal. 

Varieties. — Varieties  are  clinical  according  to  the  kind  of  infection. 
Primary  anterior  gonococcal  acute  urethritis,  sexually  acquired,  is  in 
the  male  at  first  always  meatal  and  in  the  female  likewise,  although 
the  vulva,  vagina  and  cervical  canal  may  be  attacked  at  the  same 
time;  but  if  instrumentally  acquired,  the  organisms  may  be  much 
more  widely  distributed  at  the  outset.  This  variety  is  therefore  at 
first  anterior  and  extends  backward,  and  as  a  rule  an  acute  posterior 
gonococcal  urethritis  may  appear,  if  primary,  as  a  direct  extension 
backward  of  anterior  infection,  or,  if  secondary,  as  a  relapse  of  per- 
sistent chronic  infection  or  as  a  reinoculation  from  an  old  dormant 
focus. 

ETIOLOGY  IN  GENERAL. 

The  etiology  of  acute  urethritis,  in  general,  is  recognized  as:  (1) 
specific,  having  the  one  definite  unvarying  cause,  the  gonococcus;  (2) 
nonspecific,  having  variable  causes,  bacterial  and  nonbacterial,  but 
never  the  gonococcus.  In  this  work  the  terms  gonococcal  and  non- 
gonococcal are  standard.  A  bacteriologic  differential  diagnosis  is 
always  essential  because  the  symptoms  and  courses  of  both  forms  are 
frequently  duplicates. 

Nongonococcal  Acute  Urethritis. — Nongonococcal  acute  urethritis  is 
variously  systemic  or  local,  predisposing  or  exciting,  intraurethral  or 
extraurethral,  bacterial  or  nonbacterial.  Systemic  and  local  are  the 
inclusive  subdivisions. 

Classification  of  causes  of  such  a  condition  as  m-ethritis  caim.ot  well 
be  inclusive  or  exclusive  because  causes  which  in  some  cases  are  pre- 
disposing and  systemic  may  become  exciting  and  local  in  other  cases. 
The  following  may  be  regarded  as  a  general  perspective  analysis. 

The  predisposing  systemic  factors  are  low  vitality,  semi-invalidism 
and  acute  or  chronic  alcoholism.  Conditions  causing  hyperacid  or 
hyperalkaline,  crystal-laden  urine,  as  in  gout,  rhemnatism,  diabetes, 
lithiasis,  tubercubsis  and  the  strumous  state,  all  lead  to  the  so-called 
diathetic  urethritis.  Toxemias  act  in  the  exanthemata,  possibly 
through  bacteria  and  toxins,  and  as  in  eczema  through  concentration 
of  urine  and  in  herpes  progenitalis,  chiefly  through  local  irritation,  all 
causing  so-called  eruptive  urethritis.  All  these  elements  are  usually 
predisposing,  extraurethral  and  nonbacterial. 


20  ACUTE  URETHRITIS 

Predisposing  local  factors  are  a  niucosa  vuliierMl)lc  hy  ])rovi()us 
attacks  and  especially  by  tlie  presence  of  the  uninfective  chronic  lesions 
of  gonococcal  urethritis  such  as  ulceration,  granulations,  polypi,  fibrosis 
and  stricture,  and  a  nuicosa  congested  and  irritable  by  alcoholism,  hyper- 
acidity, alkalinity  and  sediment  in  the  urine,  sexual  excess  and  sexual 
perversions.    These  are  the  predis])osing  and  intraurethral  elements. 

Periurethral  disease,  ])articularly,  prostatism  in  the  male,  and  in 
the  female  uterine  displacement,  postpartum  Aaginal  laceration  and 
deformity  may  be  predisposing  extraiu'ctin-al  factors. 

U])on  the  mucosa,  as  on  a  soil  so  prepared  any  organisms  may  find 
ready  growth. 

The  exciting  factors  in  nonbacterial  lesions  are:  (1)  traumatisms, 
thermal  from  too  hot  or  cold  irrigations,  chemical  from  too  concentrated 
ai)plications,  (2)  medicinal  from  drugs  irritant  after  internal  adminis- 
tration such  as  the  balsams,  cantharides,  alcohol,  turpentine,  and  after 
eating  such  vegetal)les  as  asparagus,  rhubarb,  tomatoes,  strawberries 
and  the  like,  and  (3)  physical  from  rough  instrumentation. 

Traumatism  may  involve  any  healthy  mucosa  but  is  most  potent  in 
the  unhealthy-  cases  and  rests  on  the  use  of  rough,  rusty  or  ragged 
instruments  as  well  as  unskilled  and  forceful  manipulation.  The 
olVense  of  indwelling  catheter  is  a  familiar  traumatism  and  in  this  class 
belong  masturbation  and  sexual  excitement  without  coitus.  Caution 
should  always  be  exercised  to  pass  smooth  instruments  and  with, 
gentleness,  never  to  use  api)lications  of  extremes  of  temperature  or 
concentration,  and  never  to  repeat  treatment  at  intervals  too  short  for 
a  recovery  period. 

Exciting  factors  in  bacterial  urethritis  are  Micrococcus  catarrhalis  in 
true  catarrhal  forms,  Treponema  jjallidvm  in  syphilitic  types,  the 
Bacillus  of  Ducrey  in  chancroidal  invasions,  and  the  ordinary  pyoge)iic 
organisms  in  simple  pus  cases.  Bacillus  coli  communis  is  often  seen. 
Bacteria  are  doubtless  a  factor  in  the  majority  of  cases,  hence  the 
im])ortance  of  bacterial  investigation. 

Catarrhal  Acute  Urethritis. — Catarrhal  acute  urethritis  is  caused  by 
tile  Microcomis  cnforrhdli.s  which,  in  mori)hol()gy,  is  the  duplicate  of  the 
gonococcus.  It  is  at  first  gram-positive,  later  gram-negative,  chiefly 
extracellular,  frequently  intracellular,  and  cannot  be  distinguished  from 
the  gonococcus  in  these  circumstances  except  by  culture. 

Syphilitic  Acute  Urethritis.— Sy])liilitic  acute  uretliritis  is  chancrous 
and  usually  meatal  or  just  i)osteri()r  to  it,  nuirked  with  edema  and 
infiltration  even  to  stricture  and  stenosis,  with  seropurulent  or  sero- 
sanguineous  discharge  present  only  in  the  first  glass  of  urine,  and  as 
a  rule  without  any  shred  stage.  Its  resolution  is  slow  without  intensive 
antisyphilitic  treatment.  Occasionally  subpreputial  chancres  and 
mucous  patches  may  cause  involvement  of  the  meatus.  The  organism 
is  the  Treponema  pallidum. 

Chancroidal  Acute  Urethritis.—  Chancroidal  acute  urethritis  is  much 
the  same  as  sy])liilitic  urethritis  in  its  location  and  effects.  The 
organism  is  tlie  Bacillus  of  Ducrey. 


BACTERIOLOGY  IN  GENERAL 


21 


Etiology  of  Gonococcal  Acute  Urethritis.— (gonococcal  acute  urethritis 
has  invariably  the  gonococcus  discovered  })y  Neisser'  in  1870  and  culti- 
vated by  Bumm^  in  1885.  This  organism  commonly  exists  in  pure 
culture,  in  most  cases  of  urethritis,  but  is  often  found  associated  with 
other  organisms. 

BACTERIOLOGY  IN  GENERAL. 

Normal  Flora  of  the  Urethra  and  Prepuce. — Before  comprehension 
oi  the  bacteriology  of  acute  urethritis  is  possible,  one  must  remember 
that  these  regions,  like  every  other  part  of  the  body,  are  normally  the 
habitat  of  various  organisms  whose  exact  influence  on  the  physiology 
of  the  part  is  not  absolutely  understood.     They  doubtlegs  serve  a 


Fig.  2. — Nongonococcal  urethritis.    Smear  from  the  urethra  of  a  case  of  nongonococcal 
urethritis  due  to  pseudodiphtheria  bacilli  (800  diameters).     (After  Lipschiltz.') 


benejBcent  purpose,  otherwise  they  would  hardly  exist  there.  Their 
importance  arises  from  the  fact  that  many  of  them  are  capable  of 
vicious  change  upon  the  advent  of  pyogenic  and  gonococcal  infection 
whose  activities  excite  them  and  are  in  turn  themselves  frequently 
augmented.  Familiarity  with  the  general  flora  of  these  parts  of  the 
body  in  both  sexes  cannot  be  neglected.  The  following  illustration 
indicates  organisms  in  an  ordinary  specimen. 

Nongonococcal  Acute  Urethritis. — Nonbacterial  Nong;onococcal  Acute 
Urethritis. — In   all  subjects,  the  urethra,  prepuce,  vulva  and  vagina 

1  Centralbl.  f.  d.  med.  Wissenschaft.,  1879,  xvii,  497. 

^  Der    Mikro-organismen  der  gonorrhoischen  Schleinshant-Erkrankungen,    "Gono- 
coccus Neisser,"  Wiesbaden,  1885. 

3  Bacteriologischen  Grundriss  und  Atlas  der  Geschlechtskrankheiten,  1913. 


22  ACUTE  URETIIRiriS 

are  normally,  in  healtli,  the  habitat  of  various  bacteria,  as  already 
stated.  These  are  iimociioiis  and  attenuated  through  long  residence 
and  ])urposeful  in  unkntnvn  degree,  but  they  may  become  nocuous  and 
h\'I)eraetive-  under  excitation  from  other  sources.  Thus  nonbacterial 
nongonococcal  acute  uretln-itis  of  traumatic,  diathetic  or  eruptive 
origin  nia\-  be  converted  into  the  bacterial  tyi)e. 

Bacterial  Nongoriococcal  Acute  Urethritis.^ — The  organisms  which 
cause  l)acterial  nongonococcal  acute  urethritis  are  streptococci,  staphy- 
lococci, pscii(lo(lij)htlicri(i  bacilli  and  Jhicillas  coli  coDnniniis  in  the 
pyogenic  lesions,  Micrococcus  cafarrlialis  in  the  true  catarrhal  iuHam- 
mations,  Treponema  pallidum  in  syphilitic  and  BaciUiLS  of  Dvcrey  in 
chancroidal,  and  various  organisms  in  herpetic  urethritis.  Luys^  on 
this  subject  says  that  the  most  important  are  the  streptococcus, 
stajjln/lococois,  pnciDiiococcus,  Micrococcus  fulla.v,  Micrococcus  pi/ogenes 
aureus,  Micrococcus  cercus  alhus.  Bacillus  typhosus,  Bacillus  coli  com- 
mvnis.  Bacillus  diphtherioe,  Bacilhis  tnhercidosis  and  various  sarcinse. 
A  small,  thin  bacillus  in  chains  and  clumps  is,  according  to  Finger,^ 
referred  to  by  Luns,''  the  common  saprophyte  of  the  i)repuce  and 
very  often  in  the  urethra  in  long-standing  cases.  Moscato'  reports  a 
case  of  urethritis  accom]ianying  every  attack  of  intermittent  fever. 

Catarrhal  Acute  Urethritis. — Acute  catarrh  of  the  urethra  is  caused  by 
the  Micrococcus  rafarrhalis  and  merits  special  consideration  in  all  its 
clinical  aspects. 

""I'lie  history  of  the  Micrococcus  catarrhalis  is  of  interest.  For  years 
skilled  urologists  have  been  convinced  that  there  is  a  diplococcus 
other  than  the  gonococcus  of  Neisser  capable  of  exciting  acute  inflam- 
mation in  the  sexual  and  urinary  passages  of  both  sexes.  The  general 
nature  of  such  infianunation  is  much  like  that  of  true  gonococcal 
im-asion,  but  the  s\Tnptoras  are  less  severe,  the  course  less  protracted 
and  uncertain,  the  complications  relatively  unknown  and  the  termina- 
tion in  absolute  recovery  almost  uni\'ersal.  W.  Ayres'^  has  published 
the  best  brief  review  on  this  subject  and  ((notes  in  substantiation  of  his 
observations  such  authors  as  Watson  and  Cunningham/'  E.  L.  Keyes,'' 
Mallory  and  Wright,^  Wood,^  Hiss  and  Zinsser/"  Ghon,  H.  Pfeifl'er 
and  Sederl,^^  Frosche'^  and  Kolle,  T^ibman  and  rdler'''  and  Park  and 
Williams.i^ 

1  Text-book  on  Gonorrhea,  1913,  pp.  41  and  42. 

'  Discussion  of  Gross's   jjaper,  Arch.   f.   Derm.   u.   Syph.,    1905,   ixxv,  39.     Adrian 
(reference  to  Finger):  Die  Nichtgonorrhoische  Urethritis,  Halle  a.  S.,  1905,  p.  58. 
'  Loc.  cit.  ••  II  Morgagni,  1890,  xxxii,  Parte  I  a,  627,  687-8. 

'  Am.  Jour.  Surg.,  March,  1912. 
'  Genito-urinary  Diseases.  '  Diseases  of  the  Genito-urinary  Organs. 

*  Pathological  Technic. 

•  Chemical  and  Microscopic  Diagnosis. 
'"  A  Text-book  of  Bacteriology. 

"  Ztschr.  f.  klin.  Med.,  1902,  xliv,  262* 

'^  Fliigge,  Die  Mikroorganismen,  1896,  .3d  ed.,  B.  ii,  p.  154.  These  men  describe  the 
coccus  and  state  that  R.  Pfeiffer  terms  it  kokk\is  catarrhalis.  What  R.  Pfeiffer  states  of 
its  properties  is  derived  from  oral  statement.     Hence,  R.  Pfeiffer  in  Frosche  and  Kolle. 

"  Reports  of  Mt.  Sinai  Hospital,  1903. 

"  Pathogenic  Bacteria  and  Protozoa. 


BACTERIOLOGY  IN  GENFAtAL  23 

The  morphology  of  the  Micrococcus  catarrhalis  as  descrihed  by  Lihman 
and  Celler/  quoted  by  Ayres,  is  as  follows:  ".  .  .  Almost  identi- 
cal morphologically  with  the  meningococcus,  but  differing  from  it 
culturally,  is  an  organism  found  in  normal  and  in  some  pathological 
conditions  on  mucous  menit)ranes  of  the  respiratory  tract,  in  the  eye, 
the  ear  and  occasionally  in  the  urethra.  This  is  the  Micrococcus 
catarrhalis  of  Pfeiffer. 

"In  spreads  this  organism  appears  also  as  a  diplococcus,  with  some 
flattening  of  the  adjacent  sides  of  the  individual  cocci.  It  decolorizes 
with  Gram's  solution.  There  is  no  capsule.  In  all  its  characteristics 
it  bears  so  close  a  resemblance  to  the  gonococcus  that  it  can  })e  differ- 
entiated therefrom  under  the  microscope  only  with  great  difficulty. 

"  Points  of  Difference. — The  tetrads  formed  by  the  meningococcus, 
as  well  as  the  large  forms  already  mentioned,  will  sometimes,  however, 
serve  to  differentiate  this  from  the  other  two  organisms.  Further,  the 
individuals  of  the  Micrococcus  catarrhalis  are  more  nearly  oval  than 
those  of  either  the  gonococcus  or  meningococcus. 

"On  agar  the  Micrococcus  catarrhalis  grows  profusely — therein 
differing  from  both  the  meningococcus  and  the  gonococcus — they  show 
no  growth  or  slight  on  this  medium." 

The  Micrococcus  catarrhalis  in  its  effects  is  relatively  a  less  vicious 
organism  than  the  gonococcus  but  potentially  it  is  capable  of  exciting 
all  the  symptoms  of  gonococcal  invasion.  The  symptoms  of  gono- 
coccal disease  are  fully  described  on  pages  33  to  36.  On  this  general 
subject  Ayres  draws  the  following  conclusions,  in  the  contribution 
already  cited:  "(1)  Demonstration  of  a  gram-negative  diplococcus 
within  the  pus  cells  of  a  discharge  from  the  urethra  is  net  proof 
positive  of  a  gonococcic  infection.  (2)  The  fact  that  a  man  has  an 
urethritis  which  shows  gram-negative  diplococci  is  not  proof  positive 
of  recent  exposure  to  gonorrhea  by  copulation.  (3)  Not  only  is  a 
microscopic  examination  necessary  in  all  cases  of  urethritis,  but  in  a 
certain  proportion  a  culture  is  imperative.  (4)  All  cases  of  urethritis 
beginning  as  a  subacute  inflammation  should  be  regarded  with  suspi- 
cion. (5)  Just  because  an  urethritis  is  very  mild  at  the  start,  it  should 
not  be  classed  as  a  Micrococcus  catarrhalis  infection  until  it  has  been 
proven  so  by  culture — gonorrhea  is  too  serious  a  disease  to  be  excluded 
without  thorough  investigation.  (6)  The  Micrococcus  catarrhalis  is  not 
a  germ  of  slight  pathogenicity,  but  is  capable  of  causing  serious  and 
even  dangerous  inflammation," 

Urethritis  Due  to  Pfeiffer's^  Streptobacillus. — A  peculiar  form  of  non- 
gonococcal urethritis  has  been  described  by  Pfeiffer.  Its  characters 
are  typified  by  the  following  three  brief  case  reports.  The  lesion  as 
shown  in  the  first  case  is  practically  autogenous.  The  second  case 
features  the  appearance  of  the  inflammation  long  after  the  true  gono- 
coccal urethritis  has  ceased,  and  the  third  case  shows  its  incidence 
very  soon  after  the  gonococcal  infection.     I.  The  man  had  obstinate 

iLoc.  cit.  2  Pfeiffer,  Engwes:  Miinchen.  med.  Wchnschr.,  1916,  Ixiii,  1457. 


24  ACUTE  URETHRITIS 

acute  gonorrhea  posterior;  it  was  nine  weeks  before  a  prostatic  focus 
was  removed.  The  urethra  was  now  sterile  and  all  treatment  was 
suspended.  On  tlie  seventh  day  ai>i)eiuvd  siiontaneously  a  muco- 
purulent discharge.  Smears  showed  puiv  culture  of  the  streptohacillus. 
Same  also  cultivated  jnu-e  from  secretions.  Conditions  persisted  for 
nine  days  and  suddenly  ceased.  Diagnosis,  streptobacillary  in*ethritis 
in  a  urethra  damaged  by  gonorrhea.  Characteristic  is  the  presence  of 
very  many  bacilli  in  tlu>  ])us  cori)uscles  which  often  appear  c[uite  dark 
in  consecjuence. 

II.  ]Man  with  alleged  second  attack  of  gonorrhea  which  had  per- 
sisted for  six  weeks.  First  attack  ten  years  before;  whitish  discharge. 
Urethra  and  ])rostate  seemed  normal.  The  secretion  contained  a 
pure  culture  of  I'feifVer's  germ  for  three  weeks.  No  gonococci  at  any 
time.  No  treatment  until  urine  in  second  test  glass  was  clear.  Weak 
sublimate  injections  given  for  four  weeks  when  urine  became  quite 
sterile. 

III.  First  attack  of  gonorrhea.  Gonococci  in  urine  for  five  weeks. 
Urine  then  became  sterile  but  discharge  reai)peared  just  as  he  was 
about  to  be  released.  Pfeitt'er's  bacillus  present  alone  for  ten  days,  then 
associated  with  gonococci  from  an  overlooked  prostatic  focus. 

Gonococcal  Acute  Urethritis. — Gonococcal  acute  urethritis  is  con- 
fined sok'ly  t(^  the  (jmuivoccus,  also  known  as  Micrococcus  hlennorrhceoe, 
Neisseria  gonorrJiea,  Micrococcus  gonorrhocce  or  Diyhcoccus  gonorrhoeoe. 

Gonococcus. — This  organism  is  so  essential  to  the  purpose  of  this 
work  that  its  bacteriology  will  be  discussed  under  the  headings  of 
natural  and  m()r])hological  characters,  details  of  Gram's  stain,  cultural 
characters  and  culture  on  hmnanized  and  animalized  media.  Other 
gram-negative  cocci  will  then  be  considered. 

Natural  Characters.- — The  gonococcus  is  a  parasite.  Its  vitality 
outside  the  body  is  little  and  on  the  skin  surface  it  will  not  produce 
lesions,  but  inside  the  body,  in  its  normal  habitat  in  the  mucous  and 
serous  membranes,  it  will  live  for  many  years,  often  attenuated  and 
harmless  until  excited  by  an  outside  cause  precisely  as  in  nongonococcal 
acute  urethritis.  Its  virulence  is  well  known  and  fully  established  and 
rapidly  revives  in  A'irgin  soil,  that  is  to  say — an  infection  without 
symptoms  in  man  or  woman  transplanted  to  an  uninfected  member 
of  the  opposite  sex  will  invariably  revive  in  all  its  violence. 

Its  habitat  is  the  mucous  and  serous  membranes  primarily  in  the 
epithelial  and  endothelial  layers  and  secondarily,  by  and  after  pene- 
tration, in  the  imderlying  structures,  especially  the  subepithelial  and 
subserous  layers,  and  e\'en  the  submucous  tissue.  By  direct  continuity 
of  the  mucous  surface  it  will  infect  in  the  male  the  prepuce,  urethra, 
Cowper's  glands,  prostate,  vasa  deferentia,  seminal  vesicles,  epididymis 
and  testis,  and,  in  ecjual  degree,  in  the  female  vulva,  urethra,  vagina, 
cerAxx,  uterine  lining,  tubes  and  ovaries  and  ])eritoneum.  Its  destruc- 
tive activity  may  render  either  sex  sterile  and  practically  unsexed. 
By  absorption  into  the  system  it  will  reach  the  serous  linings  of  the 
joints,  pleura  and  endocardium,  not  infrequently  in  association  with 


BACTERIOLOGY  IN  GENERAL  25 

other  organisms.  Septicemia  from  its  constitutional  activity  is  not 
uncommon.  Immunity  against  it  after  an  attack  is  nil  hotli  against  a 
reinfection  from  a  new  host  and  against  a  relapse  from  excitation  of  an 
old  focus  within  the  same  patient.  In  this  it  differs  from  very  many 
other  infections  and  is  correspondingly  more  difficult  to  control.  Simi- 
larly it  does  not  lend  itself  to  study  through  animal  experimentation 
as  its  general  characteristics  change  in  the  process.  At  least  twelve 
different  types  of  various  virulence  and  potency  have  been  isolated. 

Morphological  Characters. — This  organism  is,  in  form,  coffee-bean 
shape  with  the  flat  surface  slightly  concave,  in  grouping,  pairs  or  fours 
with  a  distinct  interval  between  the  individual  cocci,  in  multiplication, 
nonspore-bearing  splitting  taking  place  in  one  plane  into  the  diplo- 
coccus,  or  very  exceptionally,  in  two  planes  into  the  tetrad  type,  in 
position,  intracellular  within  the  protoplasm  of  pus  and  epithelial  cells 
or  extracellular  within  the  general  exudate,  in  staining,  susceptible  to 
the  basic  aniline  dyes  such  as  methylene  blue,  Bismarck  brown  and 
gentian  violet,  in  microchemistry  gram-negative,  that  is  to  say — it 
gives  up  the  basic  dye  under  the  influence  of  Gram's  iodin  solution  as 
a  mordant  and  alcohol  as  a  decolorizer. 

Details  of  Gram's  Stain. — 1.  With  precautions  against  contamina- 
tion by  washing  the  glans  in  the  male  and  the  vulva  in  the  female  for 
meatal  or  urethral  specimens  and  by  retracting  the  vulva  and  dilating 
the  vagina  in  the  female  for  access  to  the  vagina  and  uterus  and  the 
labia  according  to  the  point  from  which  the  pus  is  sought,  and  by 
following  every  other  detail  for  securing  a  proper  specimen,  spread 
a  smear  thinly  upon  a  slide. 

2.  Dry  in  the  air  and  fix  with  gentle  heat  or  with  equal  parts  of 
ether  and  95  per  cent,  alcohol.     Drain. 

3.  Stain  two  minutes  with  any  1  per  cent,  carbolic  basic  dye  such  as 
methylene  blue  or  gentian  violet. 

4.  Drain  and  absorb  excess  of  dye  with  filter  paper,  gently  applied 
as  a  blotter  to  ink. 

5.  Flood  for  two  minutes  with  Gram's  iodin  solution,  but  do  not 
use  water  after  step  No.  4,  as  water  precipitates  the  iodin  and  hinders 
its  action. 

6.  Wash  for  about  two  minutes  with  95  per  cent,  alcohol  until  all 
color  to  the  naked  eye  is  lost. 

7.  Wash  with  water,  drain  and  dry  with  filter  paper. 

8.  Stain  for  about  one  minute  with  any  contrast  stain,  such  as 
Bismarck  brown. 

9.  Wash  with  water,  drain  and  dry  thoroughly  as  before,  and  examine 
with  a  one-twelfth  oil-immersion  lens. 

The  gonococci  being  gram-negative  and  having  surrendered  their 
original  color  will  be  stained  brown  or  the  color  of  any  other  coun- 
terstain  used,  but  the  rest  of  the  specimen  will  have  the  color  of  the 
original  dye  employed.  No  organism  shoidd  be  regarded  as  possibly 
the  gonococcus  which  does  not  possess  these  staining  qualities,  but  the 
■Micrococcus  catarrh  alis  is,  in  its  early  life-cycle,  gram-positi"S'e  and  in 
its  later  development  gram-negative.    Culture  alone  will  distinguish. 


26  ACUTE   URETHRITIS 

CuJfural  ('A«;-ac/(7-.s-.— ('ultural  cliaractcrs  are  i)eciiliar  in  tliat  the 
organism  is  very  difficult  iiuleecl  to  gnnv  artificiallx'.  Attenuated 
specimens  from  cases  of  long  stiinding  luv  said  not  to  urow  at  all  arti- 
ficially and  yet  when  ini])lanted  on  viruin,  that  is,  ])re\iously  unin- 
fected soil  in  the  mucous  surfaces  of  cithei-niale  or  female  sexual  organs, 
they  will  rapidl>'  accpiire  their  typical  virulence.  This  is  one  of  the 
facts  which  makes  the  decision  of  final  cure  so  difficult  to  make  abso- 
lute. Human  blood  seriun  seems  to  be  the  best  medium  for  the  culture 
and  the  organisms  must  not  be  chilled  in  any  way  but  nuist  be  trans- 
ferred from  the  host  to  the  medium  itself  at  body  temi)erature  and  at 
once  put  into  the  incul)ator.  Thus,  either  the  patient  shoidd  be  sent 
to  a  fully  equipped  laboratory  for  these  steps,  or  the'])hysician  himself 
nuist  have  a  suitable  incubator  for  protecting  the  inoculation  until 
transferred  to  the  laboratory,  again  fully  protected.  The  sources  of 
culture  are  the  same  as  for  slide  specimens,  namely,  free  pus,  shreds 
and  urinary  sediment  after  centrifuging.  Of  course,  every  possible 
pri'cauticm  against  contamination  must  be  exercised  and  several  days 
allowed  for  the  growth  to  apj)ear,  which  is  invariably  slow. 

Culture  of  the  gonococcus  is  delicate  and  difficult,  best  on  Inunanized 
media  and  least  successful  on  animalized  media.  Solid  slant  medium 
in  a  test-tube  seems  much  more  advantageous  than  fluid  medium. 
Humanized  ^^reparations  have  the  following  formulas:  Wertheim^ 
uses  a  solid  media  human  serum  from  hydrocele  ascites  or  blood,  mixed 
with  meat  infusion  agar  two  or  three  parts  and  glycerine  (>  per  cent,  or 
glucose  1  per  cent.  Fluid  media  contain  human  l)lood  serimi  mixed 
with  meat  infusion  peptone  broth  having  peptone  up  to  2  per  cent. 
A  dro])  of  human  Idood  also  may  be  smeared  over  a  ])late  as  in  Pfeiffer's 
method  ftr  the  bacillus  of  influenza.  Animalized  media  are  agar  mixed 
with  natural  rabbit's  Idood  or  Wassermann's  serum-nutrose  of  swine. 

wSurface  inoculations  show  the  organism  to  be  aerobic;  stab  inocu- 
lations into  solid  media  fail  as  the  organism  is  not  anaerobic  and 
inoculations  into  fluid  media  are  followed  by  growths  only  at  the  sur- 
face for  the  same  reason.  The  temperature  or  growth  is  37.5°  C,  death 
ensuing  at  38.5°  C.  and  at  30°  (\  Colonies  of  the  gonococcus  are  thin 
gray  or  o]:)alescent  spots  looking  much  like  varnish  dropped  on  the 
medium  slightly  "bloomed."  (irowth  should  appear  in  about  twenty- 
four  hours.  Merging  of  the  colonies  does  not  occur  and  stickiness  of 
the  growths  is  a  diagnostic  feature. 

Other  gram-negative  cocci  when  compared  with  the  gonococcus  in 
urethral  infections  become  exceedingly  important  and  their  differential 
features  in  the  laboratory  are  shown  by  the  following  table.  It  becomes 
extremely  imi)ortant  for  the  urologist  to  know  the  cocci  in  this  group 
which  includes  the  Micrococcus  catarrhalis,  Micrococcus  intracellvlaris, 
Micrococcus  gonorrhoccp,  clear  micrococcus  and  opaque  micrococcus, 
both  from  Hartford's  case  of  influenza-like  e])idemic,  micrococcus  from 
the  urethra.  Micrococcus  mcliiensis  and  ^lalta  fever.  Their  character- 
istics should  be  similarly  familiar. 

>  Arch.  f.  Gynakol.,  1892. 


PATHOLOGY  IN  GENERAL 


27 


CHIEF   CIIARACTEKISTICS   OF  SIX  GRAM-NEGATIVE   COCCI. ^ 


Action  of  carbo- 

lydrates. 

-1-  = 

acid. 

alkaline. 

O  = 

no  reaction. 

Growth  on  nu- 

Organism  and  source. 

trose  acetic 

Growth  on  gela- 

Pathogenicity. 

u 

agar  at  37°  C. 

tin  at  20°  C. 

. 

i 

6 

t.4 

o 
o 

a 

1 

3 

-3 
O 

"o 

o 

o 

S 

M.    catarrhalis    nasal 

Opaque;  granu- 

Positive (grows 

Mice     and     guinea- 

and  pharyngeal  dis- 

lar. 

on       ordinary 

pigs   by  intraperi- 

charge. 

agar  at  37°  C. 

toneal  inoculations. 

— 

— 

— 

M.  intracellularis 

Clear,  smooth. 

Negative. 

In  some  cases  mice 

(meningococcus) , 

and  guinea-pigs  by 

cerebrospinal    men- 

intraperitoneal in- 

ingitis. 

oculations. 

+ 

+ 

+ 

— 

M.  gonorrhoeae  (gono- 

No  growth  un- 

Negative. 

In  some  cases  mice 

coccus) ,        urethral 

less  blood 

and  guinea-pigs  by 

discharge. 

added. 

intraperitoneal  in- 

oculations. 

+ 

+ 

o 

O 

From  nasal  discharge 

Clear,     smooth 

Negative  at  first, 

Mice     and     guinea- 

from         Hartford's 

and    becomes 

later    positive 

pigs  by  intraperi- 

case    of    influenza- 

yellowish. 

(grows  on  or- 

toneal inocula- 

+ 

■   — 

+ 

— 

like  epidemic. 

dinary  agar  at 
37°  C. 

tions. 

From  nasal  discharge 

Opaque,  granu- 

Negative. 

Mice     and     guinea- 

from         Hartford's 

ular. 

pigs  by  intraperi- 

case   of    influenza- 

toneal inocula- 

like epidemic. 

tions. 

+ 

-f 

+ 

-1- 

From  urethra. 

Opaque;   some- 
what     granu- 
lar;      smooth 

Negative. 

Mice     and     guinea- 
pigs  by  intraperi- 
toneal inocula- 

edges. 

tions. 

-1- 

-f- 

-1- 

+ 

M.  melitensis;  Malta 

Creamy        and 

Positive. 

Monkeys,   also  rab- 

fever. 

slightly      yel- 
lowish. 

bits    and    guinea- 
pigs,  by  intracere- 

bral  inoculation. 

O 

o 

o 

PATHOLOGY  IN  GENERAL. 

General  considerations  must  include  the  fact  that  mucous  membrane 
has  comparatively  little  recovery  power  from  the  effects  of  a  single 
severe  attack,  repeated  invasions  or  a  prolonged  involvement.  The 
surface  epithelium  is  denuded  readily  and  when  restored  may  lack 
the  original  characters,  being  changed  from  cohmmar  to  squamous. 
The  glands  furnishing  moisture  to  the  membrane  and  the  cavity  of  the 
urethra  are  readily  changed  so  that  their  secretion  instead  of  being  thin 
and  almost  invisible  becomes  thick,  tenacious  and  yellow,  often  mixed 
with  pus  cells  and  desquamated  epithelium.  Many  glands  lose  their 
power  of  secretion  and  surrounding  glands  take  up  overactivity  in  com- 
pensation and  the  condition  becomes  chronic.  Similarly  round-cell  and 
fibrous  infiltration  often  replace  the  mucous  membrane  in  its  essence, 
and  the  condition  remains  chronic  in  character.  Restitution  of  chronic 
lesions  is  never  fully  made,  no  matter  what  their  nature  is,  and  the 
'various  stages  leading  up  to  the  permanent  lesions  are  also  very  difficult 
to  control  or  change. 

Nongonococcal  Acute  Urethritis. — Nongonococcal  acute  urethritis 
varies  in  pathological  details  with  the  forms  previously  enumerated, 

1  Dunn  and  Gordon:  British  Med.  Jour.,  1905,  ii,  427. 


-.^  ACUTE  URETHRITIS 

namely — catarrhal,  eruptive,  iHathetic,  i>yogenic,  syphilitic,  chan- 
croidal ami  herpetic.     Kach  has  its  own  i)athology. 

Catarrhal  Acute  Urethritis  is  in  essence  a  local  or  general  hyperemia, 
^vith  edema  and  occasionally  slight  hemorrhage.  It  has  stages  of 
onset,  estahlishment  and  subsidence  each  in  itself  and  all  combined,  as  a 
rule,  rather  brief  except  with  ])ersistence  of  the  exciting  cause.  It  may 
be  anterior,  j^osterior  or  anter()i)osterior  in  distribution.  Its  exndate 
is  nuicus  or  serum  in  the  mild  cases,  mixed  with  pus  in  the  severe  cases, 
each  type  having  a  i)rogressing  degree  of  desquamation  of  epithelinm. 
Its  involvement  inchules  the  ei)ithelium  and  the  glands  of  the  mucosa 
and  rarely  the  submucosa,  in  lesions  which  are  tem])orary,  and  rarely 
with  associated  comi)licating  or  permanent  factors.  The  lesions  are 
located  in  the  mucous  membrane  alone  and  distributed  locally — ante- 
riorly, posteriorly,  or  anterojiosteriorly.  The  gross  and  microscopic 
features  are  those  standard  for  catarrhal  exudative  inflammation. 
Bacteria  may  be  jmictically  absent  or  compnse  chiefly  the  Micrococcus 
catarrJiaU.'f.    Toxins,  therefore,  do  not  play  an  im])ortant  role. 

Diathetic  and  Eruptive  Acute  Urethritis. — Diathetic  and  eruptive 
acute  urethritis  duplicate  that  of  catarrhal  forms  adding  the  special 
urinary  findings  of  the  diathetic  and  the  associated  lesions,  especially 
in  the  crui)tivc  diseases,  such  as  eczema,  the  exanthemata  and  the  like. 

Pyogenic  Acute  Urethritis. — Pyogenic  acute  urethritis  is  that  of  a 
purulent  mucous  membrane  inflammation,  local  or  general  in  distri- 
bution.    Its  essence  is  infection  with  the  pyogenic  organisms. 

Its  stages  are  those  of  infection — early  and  brief  catarrhal  inflam- 
mation, rapidly  followed  by  purulent  manifestations  and  extension 
from  its  early  local  site  with  finally  slow^  recovery.  Each  stage  in  itself 
and  all  combined  are  prolonged  and  may  leave  behind  a  mucous  mem- 
))rane  damaged  as  much  as  may  gonococcal  infection.  Its  exudate 
is  finally  pus  in  all  cases  with  blood,  mucus  and  ei)ithclium — all  in 
quantity  varying  wdth  the  severity.  Its  invoh'ement  includes  the 
epithelium  and  the  glands  of  the  mucosa  at  first,  then  the  submucosa 
and  even  the  underlying  tissues  of  complicated  cases.  The  lesions  are 
temporary  only  in  the  ^•ery  mild  cases  but  severe  forms  by  the  exten- 
sion of  the  infection  lea\-e  permanent  sequels  in  the  mucosa  and  compli- 
cating results  m  surrounding  organs.  The  gross  and  microscopical 
features  are  those  typical  of  suppurative  mucosal  inflammation,  com- 
monly located  in  the  mucous  membrane  alone  in  all  its  layers  and 
distributed  locally  or  throughout  the  urethra.  Bacteria  are  always 
present,  especially  Bacillus  coli  communis,  Streptococcus  pyogenes  and 
StcqjJn/lococciis  pyogenes,  w'hose  toxins  excepting  in  the  complicating 
cases  a])pcar  to  ha\'e  little  effect  systemically  on  the  disease. 

Syphilitic  Acute  Urethritis. — Syphilitic  acute  urethritis  is  the  path- 
ology of  chancre,  meatal  or  intrameatal  in  its  location.  Its  essence  is 
invasion  by  the  Treponema  pallidum  with  the  .small,  round-cell  infil- 
tration in  the  effort  of  nature  to  combat  the  process.  Its  stages  are 
those  of  nodulation,  superficial  or  deep  ulceration  and  slow  healing. 
Each  period  is  in  itself  and  all  combined  are  rather  prolonged  and  leave 


PATHOLOGY  IN  GENERAL 


29 


behind  a  scar-like  mass  which  rarely  fully  disappears.  Its  exudate  is 
serum,  not  autoinoculable,  in  all  cases  mixed  with  blood  during  deej) 
ulceration  and  with  pus  if  an  associated  organism  is  present.  Its 
involvement  includes  the  mucosa  in  all  its  layers  and  the  submucosa, 
so  that  more  or  less  obstruction  of  the  canal  results.  Its  gross  features 
are  those  of  pure  or  mixed  infection  in  an  ulcer  having  a  definitely, 
though  variably,  infiltrated  base,  and  its  microscopical  features  are 
those  of  small  round-cell  and  fibrous  infiltration  in  the  base  and  necrosis 
in  the  ulcer.  The  organism  is  the  Treponema  pallidum  alone  or  asso- 
ciated with  various  pyogenic  organisms.  The  organism  of  syphilis, 
its  circulation  through  the  system  and  its  toxins  with  their  effects  are 
foreign  to  the  purpose  of  this  work  or  further  discussion  concerning 
temporary  complicating  and  permanent  lesions. 


Fig. 


3. — Treponema  pallidum  from  a  chancre.     The  figure  reveals  a  dark  field  illumi- 
nator picture  with  the  organisms  moving  across  it.     (After  Lipschutz.i) 


Occasionally  mucous  patches  in  the  second  stage  or  in  the  uncleanly 
in  any  stage  of  syphilis  may  appear  in  crops  under  the  prepuce  and  one 
or  more  of  them  locate  in  the  meatus  in  the  male  or  similarly  m  the 
female  about  the  vestibule  and  meatus.  They  then  behave  in  pathology 
much  as  the  chancre  in  causing  acute  urethritis. 

The  presence  of  the  Spirocheta  halanitidw  in  the  normal  and  inflamed 
prepuce  renders  its  distinction  from  the  Treponema  pallidum  necessary  at 
times  by  culture.  The  following  illustration  t^'pifies  the  general  charac- 
ters of  the  treponema  after  the  recognized  method  of  the  dark  field 
illumination  and  merits  study. 

1  Loc.  cit. 


30  ACUTE   URETHRITIS 

Chancroidal  Acute  Urethritis. — The  ])ath()logy  of  cliMiicroidal  acute 
uivthritis  is  that  of  c-haiicroid,  luoatal  or  intraiiicatal  in  location.  Its 
essence  is  infectit)U  with  tlie  Ihtcillius-  uj  Ducreij  with  necrotic  ulceration. 
Its  stages  are  those  of  early  ulceration,  circumscribetl  cellulitis,  slow 
liealing  at  some  points  with  extension  at  others  and  final  healinj!;  with 
excavated  scar.  Its  exudate  is  autoinoculahle  pus  mixed  with  blood 
anil  detritus.  Its  involvement  includes  the  nnicosa  in  all  its  layers  and 
the  underlyuig  structures  so  that  deformity  of  the  canal  or,  less  fre- 
quently, stenosis  is  produced  by  the  scar.  Its  gross  features  are  those 
of  pure  or  mixed  infection  in  an  ulcer  with  an  excavated,  und(>rmin(>d, 
sloughing  base,  and  its  microscopical  features  are  those  of  iuHltration, 


Fig.  4. — Chancroid  or  venereal  ulcer.    Smear  from  the  secretion  of  the  depths  of  a  soft 
sore  (8U0  diameters).     (After  Lipschiitz'). 

edema,  necrosis  and  fibrous  healing.  The  organism  is  the  Bacillv.s  of 
Ducrey,  often  mixed  with  pus-producing  germs.  The  chancroid  itself 
is  usually  a  temj^orary  lesion  but  may  show  rapid  and  widespread 
l)hagedenic  (jualitics.  The  ])ermanent  lesion  is  the  scar  after  healing 
and  lyni])liangeitis  and  inguinal  adenitis  are  frequent  associated  lesions. 
Further  discussion  is  unnecessary  for  the  purposes  of  this  work. 

Herpetic  Acute  Urethritis. — The  pathology  of  herpetic  acute  urethritis 
includes  the  features  of  the  herpetic  vesicles  situated  at  or  within  the 
meatus.  Its  essence  and  stages  are  the  formation  of  infiltrated  papules 
which  soon  show  a  little  vesicle  on  their  sunuiiit  filled  at  first  with  serum, 
then  with  pus,  spontaneously  bursting  and  Iea\ing  a  superficial  ulcer 
unless  invasion  with  pyogenic  organisms  now  occurs.  Its  exudate  is 
at  first  serous,  then  purulent,  and  its  involvement  hardly  more  than  the 

'  Loc.  cit. 


PLATE  I 

FIG.   1 


Transverse  Section  through  Entire  Urethra  and  Tunica 
Albuginea  with  Round-cell  Infiltration  of  the  Urethra  and 
Mucous  Follicles.     (After  Taylor.^) 

The  whole  folded  lumen  of  the  urethra  is  surrounded  by  a  deep  ring  of  small 
round  cells  (zj,  which  seem  mainly  to  have  eonie  fronn  the  superficial  vessels 
of  the  nnucosa,  while  a  part  of  them  may  be  proliferated  connective-tissue  cells. 
The  epithelial  lining  of  the  urethra  is  desquamated,  and  is  entirely  absent  in 
places  {x,  X,  x) ,  while  in  other  places  (,y,y)  it  is  still  in  proper  position,  although 
infiltrated  with  pus  cells.  In  the  roof  of  the  urethra,  in  this  section,  the  duets 
of  the  mucous  glands  at  various  depths  are  also  surrounded  by  a  heavy  infil- 
tration of  sniall  round  cells  which  indicate  an  extension  of  the  inflannniation  along 
the  mouths  of  the  glands  from  the  surface  of  the  urethra  [w,  «■). 

FIG.   2 


Ulcer  of  the  Urethra  with  Round-cell  Infiltration  of  Floor 
and  Erosion  of  Epithelium  of  its  Surface.  Ne\^dy  Fornied 
Capillaries  are  in  Red.      (After  Taylor. i) 


Genito-urinary  and  Venereal  Diseases,  3d  Ed..  1914 


PATHOLOGY  IN  GENERAL 


31 


epithelial  layer  with  a  little  firm  edema  beneath.  Its  gross  features 
are  those  of  a  superficial  sore  with  reddened  base,  or  a  small  vesicle 
or  pustule  on  such  a  base  according  to  stage,  and  its  microscopic 
features  are  those  of  epithelium  detached  into  the  vesicle  or  pustule 


.^/     -^11*. 


Fig.  5. — Section  of  urethral  roof  with  round-cell  infiltration  of  mucosa  and  follicles, 
more  highly  magnified  than  the  Fig.  1  in  Plate  I.  "Fig.  5  shows  the  invasion  of  the  urethra 
by  the  gonorrheal  process  still  more  plainly.  The  drawing  includes  the  whole  thick- 
ness of  a  segment  from  the  roof  of  the  urethra,  corresponding  to  the  rectangular 
area  indicated  by  p,  q,  in  Plate  I,  Fig.  1.  With  this  higher  magnifjdng  power  in  Fig.  5, 
the  infiltration  of  the  mucosa  and  tissue  surrounding  the  tubidar  ducts  of  the  mucous 
glands  is  shown  in  detail.  With  the  exception  of  the  patches  denoted  by  x  and  y,  the 
epithelial  lining  of  the  urethra  is  absent,  so  that  there  are  extensive  areas  of  erosion  of 
the  infiltrated  mucosa.  Lying  free  in  the  uretlu^al  lumen  near  the  denuded  surface  is  a 
flake  of  the  gonorrheal  exudation  (z,  z.  Fig.  5).  This  flake  is  quite  identical  in  structure 
with  the  ordinary  gonorrheal  discharge  as  seen  on  a  cover  glass,  and  consists  mainly  of 
pus  cells  lying  in  a  fluid  or  granular  matrix.  The  mucosa  just  beneath  what  is  left  of 
the  epithelial  lining  is  very  densely  crowded  with  small  round  cells  to  the  extent  shown 
in  the  figure  at  v,  v.  In  the  same  way  the  ducts  of  the  mucous  glands  u,  w,  and  r,  and  in 
places  the  gland  acini  themselves  (t)  are  similarly  infiltrated  ■with  the  small  round  cells. 
The  ducts  w  and  r  have  their  lumina  partially  filled  with  desquamated  cells  and  graniilar 
material."     (Taylor.i) 

and  the  surrounding  edema  and  infiltration.  No  definite  organism  has 
been  isolated  and  the  lesions  are  temporary  without  permanent  or 
associated  elements,  scarring  occurring  only  after  mixed  infection. 

Gonococcal  Acute  Urethritis. — Gonococcal  acute  uretlii-itis  is  a  superfi- 
cial or  penetratmg  suppurative  inflammation  of  the  mucosa  according  to 


1  Genito-urinary  and  Venereal  Diseases,  Philadelphia,  Lea  &  Febiger,  1904. 


32  ACUTE  URETHRITIS 

intensity.  Primary  cases  conijn'iso  the  first  attack  and  secondary  cases 
are  subsequent  fresh  reinfections  of  cured  cases  or  sequels  of  uncured 
cases  or  relapses  of  tlie  latter  without  the  element  of  reinfection.  Its 
essence  is  infection  hy  tlie  gonocoecus  and  its  stages  are  incubation  of 
catarrhal  ty]x\  early  estal)lishnient  of  desciuaniative  character  and  full 
invasion  or  acme  of  suppurative  features  with  death  of  epithelium  and 
leukocytes.  Its  exudate  is  autoinoculable  and  heteroinoculable  pus 
containing  ei)ithelium,  white  cells,  red  cells  (all  degenerated  into  pus 
cells)  and  nnriads  of  gonococci — all  luixed  in  a  fluid  basis  of  serum  and 
mucus.  In  distribution  it  regularly  liegins  at  the  meatus  in  the  male, 
if  sexually  acquired,  and  in  the  female  at  almost  any  point  but  usually 
the  urethra  and  vuh'a  are  early  involved  or  the  vault  of  the  vagina  and 
cervix  through  intimate  contact  with  the  infecting  ejaculation.  Relap- 
sing cases  begin  at  any  focus  and  progress  therefrom.  Extension  follows 
rapidly  in  continuity  of  surface  so  that  in  the  male  the  lining  of  the 
foreskin  and  the  urethra  from  end  to  end  suffer,  making  the  so-called 
anterior,  posterior  and  anteroposterior  cases,  and  so  that  in  the  female 
the  external  genitals,  urethra,  vagina,  endometrium,  oviducts  and 
peritoneum  may  become  involved.  The  lesions  are  deepest  where 
oldest  with  rare  exceptions.  The  gross  features  of  the  disease  are  in 
regular  sequence  catarrh  with  edema,  followed  by  more  or  less  hemor- 
rhagic suppuration.  The  microscopic  features  are  hyperemia,  denuda- 
tion, hemorrhage,  pus-cell  and  tissue-cell  infiltration,  with  gonococci  in 
the  pus  cells,  epithelial  cells  and  free  in  the  pus  and  tissues.  All  these 
features  are  found  in  the  mucosa  in  various  and  every  layer  and  in  the 
periurethral  structmes  in  severe  cases  and  in  surrounding  organs  in 
complicated  cases.  Penetration  into  the  depths  of  the  mucosa  precedes 
and  accompanies  extension  along  the  surface.  The  first  thirty-six  hours 
are  concerned  with  the  incubation,  during  which  the  superficial  cells 
are  passed  and  the  subepithelial  connective  tissues  reached.  The 
second  thirty-six  hom-s  reach  the  stage  of  invasion  with  early  exudate 
and  are  characterized  by  desquamation,  pus-formation,  diapedesis  of 
leukocytes,  capillary  congestion,  arteritis,  phlebitis  and  lymphatic 
and  glandular  envolvement.  Termination  is  marked  by  the  subsidence 
of  active  hy])eremia,  decrease  and  finally  disappearance  of  gonococci 
and  repair  of  the  damaged  mucous  membrane,  if  recovery  is  complete; 
but  if  incomplete  the  disease  may  be  protracted  at  almost  any  focus  and 
in  any  degree,  thus  constituting  gonococcal  chronic  urethritis. 

The  pathological  varieties  are  therefore  acute,  subacute  and  chronic, 
primary  and  secondary,  uncomplicated  and  complicated. 

Nature's  combat  against  the  disease  is  shown  in  the  hyperemia,  in 
the  dia]:)edesis  and  phagocytosis  of  the  leukocytes  and  in  the  serimi  of 
lymphatic  activity  and  shown  in  the  exudate  by  the  casting  off  of  dead 
and  dying  epithelial  and  white  bloodcells  and  the  fluid  elements  of  the 
pus,  all  containing  the  gonococci,  and  shown  in  the  repair  process  of 
tissue  proliferation  to  restore  the  loss  and  again  shown  in  the  resistance 
of  the  serum  to  the  disease  for  the  destruction  of  the  organism  and  the 
neutralization  of  the  toxins.    The  systemic  effects  of  gonococcal  acute 


SYMPTOMATOLOGY  AND  STAGES  33 

urethritis,  unless  pyogenic  organisms  are  associated,  is  relatively  little 
when  compared  with  those  of  other  infections.  This  pathological 
fact  accounts  for  the  peculiarity  that  in  the  treatment  antigonococcal 
serum  and  bacterin  are  distinctly  likewise  of  less  value.  'J'here  is,  how- 
ever, a  complement  deviation  test,  also  called  complement  fixation 
test,  perfected  by  Schwartz,^  similar  to  the  Wassermann  complement 
fixation  test  in  syphilis  in  its  general  nature  and  interpretation  of  the 
disease.  Pathologically,  therefore,  a  positive  test  denotes  presence  of 
the  disease  while  a  negative  may  mean  its  absence  whose  definiteness 
and  permanence,  however,  are  as  yet  less  understood  than  those  of 
positive  reactions  and  can  be  interpreted  only  after  years  of  further 
observation. 

The  temporary  lesions  of  gonococcal  acute  urethritis  occur  only  in 
mild  cases  or  in  areas  of  mucosa  least  involved.  In  severe  cases,  its 
permanent  lesions  are  almost  inevitable  and  comprise  destruction  of 
the  mucosa  and  its  glands  in  varying  degree  along  with  similar  processes 
in  an  organ  secondarily  attacked  in  complicated  cases  and  result  in 
the  lesions  of  chronic  urethritis  which  must  be  discussed  as  a  separate 
subject  (see  page  263).  Its  complicating  lesions  when  localized  in  the 
sexual  organs  of  both  sexes  involve  the  mucous  glands  and  follicles, 
periurethral  tissues  and  lymphatics  extending  in  the  male  to  Cowper's 
glands,  the  prostate,  vasa  deferentia  and  testicles,  and  in  the  female  to 
the  vulvovaginal  glands,  vagina,  endometrium,  tubes,  ovaries  and  peri- 
toneum, and  when  reaching  the  urinary  organs  in  both  sexes  involve 
the  bladder,  ureters,  and  kidneys.  The  process  is  in  every  pathologic 
feature  the  same  in  glands  or  organs  secondarily  and  complicatingly 
attacked  as  in  the  urethra  itself  in  primary  uncomplicated  acute 
urethritis.  Its  lesions  of  absorption  or  penetration  of  the  organisms 
involve  serous  membranes  other  than  the  peritoneum,  notably  endo- 
cardium, pleur?e  and  joints.  Death  from  gonorrhea  is  by  no  means 
unknown,  although  rare,  as  a  process  of  general  septicemia.  Lesions 
predominate  in  any  part  of  the  canal  and  constitute  in  this  manner 
anterior,  posterior  and  anteroposterior  urethritis,  each  having  its  appro- 
priate symptoms  under  the  same  titles  as  described  hereinafter. 

Gonococcal  Chronic  Urethritis. — Pathology  of  gonococcal  chronic 
urethritis,  on  account  of  its  many  important  clinical  factors,  is  treated 
as  a  separate  subject  in  Chapter  IV,  page  265. 

SYMPTOMATOLOGY  AND  STAGES. 

Point  of  Onset. — The  disease  regularly  begins  at  the  meatus  in  both 
sexes  in  sexually  acquired  primary  cases  and  in  the  female  also  at 
the  vulva,  vault  of  the  vagina  or  cervix  in  accordance  with  the  various 
points  of  inoculation.  It  is,  therefore,  at  first  always  anterior  in  the 
urethra.  Secondary  or  relapsing  acute  disease  may  begin  at  any  point 
of  the  urogenital  tract  in  either  sex  from  a  focus  of  chronic  infection; 

»  Schwartz,  H.  T.,  and  McNeil,  A.:  Am.  Jour.  Med.  Sc,  1911,  sci,  693. 
3 


34  ACUTE   UJiETIIRITIS 

thus  in  the  male  the  posterior  uretlira  or  tlie  sinToiiiuling  organs  and 
in  the  female  the  internal  sexual  organs  may  first  light  up  in  a  relapsing 
attack  before  the  distal  parts  are  engaged  secondarily  to  it. 

The  chief  local  symptoms  are  much  alike  in  both  primary  and 
secondary  cases,  namely — discomfort,  ])ain,  ])ollakiuria,  hemorrhage, 
exudate  and  chordee.  The  follmving  general  facts  of  each  symptom 
are  noted: 

General  Clinical  Features.^All  the  usual  symptoms  of  inflammation 
of  any  mucous  membrane  are  present,  varying  in  character  and  degree 
with  the  attack  itself.  All  elements  which  excite  simple  catarrhal 
urethritis  tend  to  arouse  and  augment  all  other  forms.  The  symptoms 
are  subjective,  objective  and  systemic,  concerned  with  the  system 
at  large  and  local,  iuA'olved  with  the  urogenital  system  in  particular. 
In  the  afl'ectcd  organs  pathological  processes  in  the  mucous  membrane 
give  certain  clinical  features  and  functional  derangement  causes  still 
other  signs. 

Subjective  Symptoms. — The  subjective  sjTiiptoms  are  greatest  when 
the  deci)er  layers  of  the  mucosa  are  exposed  and  the  tissues  infil- 
trated and  hemorrhagic.  Extension  into  complications  always  means 
increased  as  well  as  new  symptoms  and  often  the  advent  of  subjective 
s.Mriptoms  if  previously  absent. 

Objective  Symptoms. — The  objective  symptoms  are  concerned  in  the 
immediate  lesions  and  results  in  the  mucosa  itself,  the  discharge  and 
the  bacteriology  in  all  cases,  to  which  is  added  the  symptoms  of  compli- 
cations when  they  arise. 

Systemic  Symptoms. — The  systemic  symptoms  are  those  of  infection, 
occurring  only  in  severe  cases,  chills,  fever,  malaise,  prostration, 
anorexia  and  the  like.  Complications  are  also  apt  to  be  associated  with 
these  signs. 

Local  Symptoms.^ — The  local  sj-mptoms  should  be  described  in  detail 
and  are  comprised  in  discharge,  urinary  disorders,  functional  derange- 
ment in  all  cases  and  numerous  complications,  often  simple,  but  in 
many  cases  severe. 

Discomfort  and  sense  of  heat  are  rarely  present  during  incubation  but 
appear  ^^^th  the  his-peremia  of  the  invasion  and  its  early  serous  dis- 
charge, which  gra\'itating  to  the  floor  of  the  urethra  is  felt  there.  Vulvar 
and  vaginal  infections  closely  imitate  these  conditions.  Pain  of  dis- 
tinct and  progressing  irritating  character  marks  the  extension  of  the 
disease  along  the  passage  and  into  the  depth  of  the  mucosa.  Its  sources 
are  denudation,  pressure  of  infiltration  and  distention  of  edema  in  both 
sexes  anrl  in  any  membrane  attacked.  Bacterial  growth  and  toxins 
are  also  sources  of  pain. 

Pollakiuria  is  due  to  reflex  disturbance  in  the  urethra  in  the  anterior 
canal  of  the  male  and  in  the  Avhole  passage  of  the  female,  by  all  the 
pathologic  activities,  and  due  to  direct  irritation  of  the  sphincter  vesicae 
in  the  posterior  urethra  in  the  male.  The  hyperemia  is  the  early  and 
the  exudate  the  later  factor.  In  the  female  this  symptom  is  rather 
independent  of  vulvar  and  vaginal  involvement,  and  again  it  is  related 


SYMPTOMATOLOGY  AND  STAGES  V^h 

to  the  cutoff  muscle.  Hemorrhage,  in  streaks  through  the  exuilate  f)r 
in  drops  with  the  terminal  urine,  is  a  rare  symptom  except  in  severe 
cases,  while  free  terminal  bleeding  is  not  unknown.  Intense  congestion 
and  minute  tears  through  chordee  are  the  common  caus(;s.  lilood  as  a 
factor  under  the  microscope  is  often  seen.  Exudate  is  seriun  in  the  late 
incubation  and  early  invasion,  seromucus,  mucus  or  mucopus  in  the 
later  invasion  and  early  establishment  and  pus  throughout  the  full 
virulence  of  the  disease,  while  termination  is  marked  by  a  return  to  the 
normal,  if  at  all,  in  the  reverse  order  from  fluid  pus  to  pus  shreds,  then 
from  free  mucus  to  mucous  shreds  or  mucus  apparent  only  on  chilling 
the  specimen,  and  finally  no  exudate  at  all  in  complete  cure.  Chordee 
is  confined  to  the  male  and  is  very  painful  erection,  which  is  excited  by 
the  irritation  within  the  canal  of  extensive  urethritis  reflexly  upon  the 
spinal  cord.  Distention  of  the  bladder  with  urine  in  the  early  morning 
excites  chordee  also  precisely  as  it  does  erections  in  normal  men.  The 
pain  is  due  to  the  fact  that  the  congestion,  edema  and  infiltration  of  the 
corpus  spongiosum  urethrse  deprive  it  of  extensibility,  so  that  while 
the  corpora  cavernosa  penis  distend  and  extend  into  the  erection  the 
urethra  remains  inelastic  as  a  thick  cord  (whence  the  French  term 
chordee)  along  the  venter  of  the  penis,  compelling  the  organ  to  take 
a  curve  downward  instead  of  upward.  This  strain  on  the  urethra  is 
excessively  painful  and  may  tear  the  mucosa  at  numerous  points,  thus 
setting  up  hemorrhage. 

Stages. — Four  stages  are  recognized  for  convenience  of  description: 
incubation,  invasion,  establishment  and  termination. 

Incubation. — Incubation  is  marked  by  hyperemia  and  edema  with  few 
and  slight  subjective  and  objective  symptoms. 

Invasion. — Invasion  adds  to  all  these  conditions.  The  latter  is,  there- 
fore, the  stage  during  which  most  patients  present  themselves.  It  is 
distinguished  by  desquamation  of  epitheliimi  and  the  exudation  of 
mucus  and  serum,  with  progressively  greater  subjective  symptoms, 
pain  being  due  to  the  denudation  and  infiltration. 

Establishment. — Establishment  adds  free  discharge,  pus  formation 
and  extension  along  the  canal  until  the  whole  urethra  may  be  involved 
in  the  male  and  until  either  or  both  the  external  and  internal  sexual 
organs  may  be  compromised  in  the  female.  The  last  condition  is 
regarded  as  a  complication  exactly  as  is  similar  extension  in  the  male 
of  the  disease  into  periurethral  structures  and  organs. 

The  coviplications  are  appropriately  a  separate  subject  and  are 
treated  in  Chapter  II  on  page  82. 

Termination. — ^Termination  is  distinguished  by  subsidence  of  all 
symptoms,  often  in  a  comparatively  brief  period  in  mild  and  uncom- 
plicated cases,  but  usually  in  a  really  prolonged  period,  even  months 
and  years,  in  severe  and  complicated  cases,  which  constitute  chronic 
urethritis — a  subject  for  individual  discussion  in  the  following  chapters. 
The  symptom  last  to  leave  during  the  termination  is  in  most  cases  the 
discharge,  w^hich  gradually  decreases  in  amount  and  thickens  in  con- 
sistency exactly  like  the  mucus  from  the  bronchi  after  mfection  there . 


36  ACUTE   URETHRITIS 

Tims  are  ])ro(hiPiHl  tlio  various  kinds  of  slircd  in  the  urine  in  both  sexes 
and  striuiTs  of  nnieus  in  lencorrhea  in  the  female. 

Nongonococcal  Acute  Urethritis.  Nonbacterial  Nongonococcal  Acute 
Urethritis.  .Nonitacterial  noni;dnococcal  acute  urethritis  shows  no 
niii-ro()ri;anism  at  all  or  noni'  of  importance  as  distinunished  from  the 
bacterial  forms  to  he  presently  descrihed.  Primary  disease  is  the  rule, 
secondary  forms  are  less  common.  Incuhatiou  is  absent  or  short  within 
a  very  few  hours  or  a  day  and  without  definite  symptoms.  Invasion 
is  very  ])rom])t  after  traumatism,  physical  by  instruments,  thermic  by 
heat  or  cold,  chemical  by  concentrated  solutions,  or  early  dnrinj;'  an 
exacerbation  of  f^out  or  rheumatism  in  diathetic  urethritis,  an  outbreak 
of  eczema  or  an  attack  of  herpes  in  eru])tive  urethritis.  Onset  is  also 
autofjenous,  self-induced  by  excess  in  venery,  eatinj?  and  (lrinkin<!;  or 
by  any  other  sliijht  cause  aetinji  on  a  mucosa  weakened  by  previous 
attacks.  Inoculation  by  an  acrid  \aginal  discharfi;e  associated  with 
menstruation  or  leucorrhea  occurs  but  would  then  sufjgest  the  bacterial 
form  of  the  disease.     Establishment  is  early. 

The  subjective  symptoms  are  discomfort,  rarely  ])ain,  varial)le  polla- 
kiuria,  no  hemorrhage  unless  from  the  causative  traumatism  directly, 
and  a  scanty  exudate  of  serum  and  mucus,  all  in  the  mikl  cases  which 
are  the  rule.  Intense  degrees  of  the  disease  simulate  gonococcal  con- 
ditions. Objective  symptoms  are  the  swelling  of  the  mucous  membrane 
and  the  exudate  at  the  meatus  and  usually  only  in  the  first  glass  of 
urine  in  a  two-glass  test.  Complications  are  rare.  The  stage  of  termi- 
nation is  brief  and  recovery  com])lete. 

Bacterial  Nongonococcal  Acute  Urethritis. — Bacterial  nongonococcal 
acute  lu'ethritis  has  microorganisms  of  great  importance  and  shows 
])rimary  eases  by  initial  infection  and  not  infrequently  secondary  cases 
from  relapsing  disease.  INIild  or  severe  cases  are  the  rule  and  compli- 
cations not  unusual  especially  in  the  pyogenic  form  which  is  clinically 
indistinguishable  from  true  gonococcal  urethritis. 

Catarrhal  Acute  Urethritis. — Catarrhal  acute  urethritis  is  an  autoge- 
nous infi'ction  with  Mlcnirncciis  (■(dnrrhali.s  i)reviously  either  rendered 
active  or  the  mucosa  vulnerable  to  it  or  both  through  indiscretions  in 
intercourse,  food  and  drink  or  it  is  a  heterogenous  infection  from  host 
having  an  active  form. 

Incubation,  invasion  and  establishment  ai-e  short,  as  a  rule,  within  a 
day  or  two:  that  is,  about  half  the  incubation  of  a  gonococcal  infection 
although  longer  delays  are  seen.  The  subjective  symptoms  are  dis- 
comfort, irritation,  moderate])ollakiuriaand  seromucus  discharge  w'hich 
become  more  positi\'e  during  the  in\asion  and  later  when  the  establish- 
ment is  eomi)lete  all  these  symptoms  are  somewhat  augmented  in  mild 
cases  and  distinctly  so  in  severe  cases  occasionally  even  to  the  degree 
of  gonococcal  infection.  The  objective  symptoms  are  moderate  edema 
at  the  meatus  and  profuse  mucous  or  mueojMU-ulent  discharge.  Asso- 
ciated catarrhs  in  other  mucous  membranes  are  not  uncommon  as  in 
the  nose  and  throat  and  in  the  female  the  external  and  internal  organs 
may  take  j)art  in  the  same  process.    Complications  are  rare.    Termi- 


SYMPTOMATOLOGY  AND  STAGES  37 

nation  is  shown  by  a  rather  slow  recovery,  often  leavin^^  Ijchiiif]  either 
a  very  sHght  exudate  or  a  local  weakness  of  the  mucosa. 

Diathetic  and  Eruptive  Acute  Urethritis.-  I ) lath etic  and  eruptive 
acute  urethritis  are  essentially  aut()fi;(!iioiis  conditions,  sometimes 
without  important  bacteria,  oftener  with  M  icrococcus  catarr kalis  in  a 
soil  unhealthy  and  irritated  by  underlying  disease,  such  as  gout, 
rheumatism  or  eczema.  Pyogenic  urethritis  may  be  similarly  ushered 
in.  Incubation  is  concurrent  with  the  early  period  and  symptoms  of 
the  causative  disease  during  the  first  few  days.  Invasion,  establishment 
and  termination  have  the  same  clinical  features  as  primary  catarrhal 
urethritis,  w"ith  those  of  the  underlying  disease  added. 

Pyogenic  Acute  Urethritis. — Pyogenic  acute  urethritis  is  exceptionally 
self-induced  through  the  familiar  three  excesses  which  weaken  the 
mucosa  and  stimulate  the  organisms  commonly  dormant  as  harmless 
saprophytes  in  the  urethra,  namely,  streptococci,  staphylococci,  various 
bacilli  and  numerous  other  organisms,  usually  not  pathogenic;  but  as  a 
rule  it  is  a  direct  infection  by  sexual  intercourse,  duly  augmented  by  the 
foregoing  elements.  Incubation  is  much  the  same  as  that  of  gonococcal 
urethritis,  from  three  to  seven  days  in  the  primary  cases  and  a  shorter 
time  in  the  secondary  and  relapsing  cases.  Invasion  and  establishment 
are  marked  with  the  same  subjective  symptoms  in  the  urethra  and  during 
urination.  The  discharge  is  less  seromucous  and  early  more  muco- 
purulent and  purulent  than  in  the  preceding  form  of  urethritis  and 
likewise  more  copious.  Objective  symptoms  chiefly  concern  moderate 
edema  and  a  bogginess  of  the  urethra  as  a  whole  and  the  profuse  puru- 
lent discharge  which  cannot  be  distinguished  from  that  in  gonococcal 
urethritis  except  with  culture  and  microscope.  The  gonococcus  is 
often  associated  with  pyogenic  organisms  in  severe  urethritis  and  is, 
therefore,  always  to  be  thought  of  as  present  in  a  pyogenic  case  which 
does  not  follow  quite  the  typical  course.  Complications  are  almost  as 
common  in  true  pyogenic  urethritis  as  in  gonococcal  lesions;  in  fact, 
by  many  it  is  considered  as  doubtful  whether  rheumatism  of  urethral 
origin  occurs  unless  the  pyogenic  organisms  are  present.  Termination 
is  by  the  usual  steps  a  slow  recovery  of  the  mucosa  to  normal  in  rather 
rare  instances.  More  commonly  permanent  damage  remains  in  the 
urethra  and  in  the  surrounding  organs  infected  dm-ing  the  compli- 
cations. 

Syphilitic  Acute  Urethritis. — Sji^hilitic  acute  m-etlu'itis  is  generally 
chancrous  and  sexually  acquired  although  under  a  long  foreskin  and 
within  the  folds  of  the  vestibule  of  the  vagina  mucous  patches  dm-ing 
the  second  stage-  may  involve  the  meatus  in  a  local  m-ethi*itis.  The 
chancre  is  either  meatal,  namely,  partly  upon  the  glans  or  vestibide  and 
partly  within  the  urethra  or  endom'etlu"al — entirely  in  the  canal.  Incu- 
bation is  typically  twenty-one  days,  occasionally  shorter,  if  mixed  infec- 
tion is  present,  and  rarely  longer  if  the  history  is  correct  and  trutliful. 
Invasion  is  marked  by  infiltration  and  a  narrowing  of  the  canal  so  that 
changes  in  the  stream  occur  in  marked  cases  but  if  the  infiltration  is  of 
"parcliment"  type  it  may  escape  detection.     Establishment  of  the 


38  ACUTE  URETHRITIS 

chaiicre  or  inucoiis  patch  is  si^nallod  by  subjective  symptoms  in  its  period 
of  ulceration  through  pain  in  urination  over  the  eroded  spot  and  the 
serous  or  serosan,i,niinc()us  discharge.  Associated  balanitis,  balano- 
posthitis  and  \uhitis  give  a  seropurulent  discharge  of  typical  ai)pear- 
ance,  consistency  and  odor,  for  which  or  for  the  secondary  rash  often 
present  already  the  ])atient  is  more  apt  to  seek  treatment  than  for  the 
urethral  lesion  itself.  Objective  symptoms  are  the  infiltration,  patches, 
rash,  adenitis,  Trcpoiicnui  ixillidinn  and  the  blood  reactions  of  Wasser- 
mann  or  Noguchi  in  the  well-established  cases,  while  the  blood  may  be 
negative  in  the  earlier  cases.  Cord-like,  insensitive  lymphatic  channels 
leading  from  the  lesion  into  the  groins  are  common  and  early.  Great 
edema  of  purple  lividity  and  narrowing  of  the  caliber  of  the  lu-ethra  are 
seen.  Urethroscopy  is  ad\isable  in  selected  cases.  Complications  are 
rare  and  due  to  associated  pyogenic  infection  and  usually  are  summed 
up  in  focal  phagedena  and  in  suppiu'ative  adenitis  in  the  groins.  Ter- 
mination results  in  the  healed  lesion  with  long  persistent  infiltration  and 
at  times  pennanent  scar  and  deformity. 

Chancroidal  Urethritis. — Chancroidal  urethritis  is  almost  always  a 
])rimary  infection  sexually  acquired,  rarely  secondary  by  extension  of 
a  neighboring  lesion  or  by  infection  with  the  finger  of  the  patient  or 
instruments.  It  seems  to  l^e  chiefly  meatal  only,  rather  than  endo- 
lU'cthral,  thus  differing  from  the  chancrous  form  in  both  sexes.  Incu- 
bation is  about  one  week,  usually  less,  and  has  no  special  sj^roptoms. 
Invasion  is  that  of  an  open  ulcer,  with  pain,  pus,  bleeding  and  ardor 
urina\  Extension  and  autoinoculation  occur  again,  differing  from 
syi)hilitic  urethritis.  Establishment  marks  the  more  severe  and  pro- 
gressing symptoms  while  termination  is  ncA'er  without  permanent 
rough  scar  and  deformity,  although  not  always  extensive. 

Herpetic  Acute  Urethritis. — Herpetic  acute  urethritis  is  autogenous, 
ne\"cr  directly  infected,  and  by  some  authorities  is  classed  as  diathetic. 
It  is  as  lawless  as  herpes  of  the  face.  The  objective  symptoms  show 
papules  grouped  about  the  meatus,  glans  and  foreskin  in  males 
and  in  females  about  the  vuh'a,  which  soon  acquire  vesicles,  with 
seriun,  then  seropus  within  them,  which  break  down  into  little  ulcers. 
These  become  covered  with  scabs  in  the  healing  stage. 

The  subjective  symptoms  are  burning  during  the  congestion,  soreness 
during  the  ulceration  and  itching  during  the  scabbing  stage.  Herpes 
is  never  endourethral. 

Gonococcal  Acute  Urethritis. — Clinical  Varieties. — The  clinical  varie- 
ties are  hyperacute,  acute,  subacute  and  chronic,  uncomplicated  and 
complicated,  of  which  the  chronic  and  complicated  forms  are  properly 
subjects  by  themselves  and  are  so  treated  in  this  work. 

Anterior  and  posterior  urethritis  is  a  classification  of  practical  merit 
in  that  it  respects  anatomical  subdi\'ision  of  the  urethra  into  the  ante- 
rior and  posterior  portions  at  the  triangular  ligament,  surrounded  by 
the  compressor  urethrse  muscle,  and  respects  pathological  findings  of 
slightly  different  temporary,  permanent  and  complicating  lesions  in 
these  same  two  subdivisions,  and  respects  clinical  observation  of  totally 


SYMPTOMATOLOGY  AND  STAGES  39 

different  symptom-complex  in  accordance  with  the  part  of  the  urethra 
involved. 

Rapidity  of  onset,  severity  of  symptoms,  number  and  importance  of 
complications  and  protraction  in  course  all  vary  according  to  the 
virulence  of  the  infection,  the  presence  of  other  organisms  associated 
with  the  gonococcus,  the  general  health  and  resistance  of  the  patient 
to  disease  in  general,  and  to  mucosal  lesions  in  particular,  and  the 
early  and  properly  applied  treatment.  It  is  fully  established  that  the 
gonococcus  itself  varies  widely  in  its  virulence,  so  that  Schwartz^  has 
been  able  to  differentiate  at  least  four  general  varieties,  comprising  at 
least  twelve  subtypes  in  his  gonococcal  fixation  test  work. 

Anterior  Gonococcal  Acute  Urethritis. — The  stages  are  incubation, 
invasion,  establishment  and  termination.  Anterior  infection  is  clini- 
cally the  earliest  manifestation  of  infection  and  deserves  careful  study. 
Incubation  has  practically  no  symptoms  and  marks  the  period  of  pro- 
liferation of  the  organisms.  In  the  first  attack  it  usually  lasts  three 
days,  occasionally  reaches  seven  days  and  even  longer,  but  in  second 
and  subsequent  attacks  it  is  liable  to  be  shorter,  especially  if  sequels  of 
previous  attacks  are  active,  and  it  may  be  abbreviated  likewise  by  all 
the  causes  of  simple  catarrhal  urethritis.  The  point  of  incubation  is 
at  the  meatus  in  primary  sexually  acquired  disease,  whence  it  extends 
through  the  anterior  urethra  up  to  the  triangular  ligament.  After 
this  it  may  invade  the  posterior  urethra.  Thus  is  constituted  respec- 
tively anterior  and  posterior  urethritis,  with  highly  different  symp- 
toms. Progress  to  the  neck  of  the  bladder  makes  the  posterior  form. 
That  form  alone  is  seen  in  woman  on  account  of  anatomical  arrange- 
ment. The  symptoms  of  anterior  and  posterior  urethritis  also  vary 
accordingly  as  the  disease  is  primary,  and  extends  from  the  meatus 
backward  or  secondary,  starting  at  any  point  of  the  urethra  from 
which  it  proceeds.  The  local  subjective  symptoms  are  a  little  indefinite 
sensation,  which  slowly  increases,  and  is  like  the  tickling  of  a  hair  or 
the  creeping  of  a  fly  in  and  about  the  meatus.  The  local  objective 
symptoms  are  redness  and  edema  of  the  meatus,  a  di'op  of  pus  with 
loose  epithelium  containing  gonococci.  The  first  glass  of  urine  is  clear 
and  free  of  pus,  but  may  have  delicate  shreds  or  flakes  and  the  second 
glass  is  clear. 

The  invasion  marks  the  changes  in  the  mucous  membrane,  begin- 
ning with  early  discharge  and  persisting  a  few  days  or  a  week.  The 
local  subjective  symptoms  are  increased  tickling,  due  to  the  early  exu- 
date, and  slight  heat,  due  to  congestion  and  moderate  frequency, 
and  ardor  of  urination,  due  to  the  irritation  and  denudation.  The 
systemic  subjective  symptoms  are  anorexia,  malaise,  fever  and  prostra- 
tion. The  more  marked  the  symptoms  the  more  severe  is  the  attack 
likely  to  be,  a  fact  which  should  be  w^eU  borne  in  mind.  The  local 
objective  symptoms  are  moisture,  progressively  serous,  mucous  and 
purulent,  at  times  bloody,  scanty  or  moderate  in  amount,  gumming 

1  Schwartz  and  McNeil:  Loc.  cit. 


40  ACUTE   URETHRITIS 

the  moatus  tduether;  gonococci  abinulant,  with  opithoUal  and  white 
blood  eells,  and  urine  .-iHghtly  turbid  in  the  Krst  ghiss  and  clear  in  the 
second. 

The  estabhslnnent  bci^ins  at  the  end  of  the  second  week  or  even  earlier 
and  sometimes  nt)t  until  the  third  week.  It  is  a])proximately  true  to 
say  that  a  week  is  devoted  to  incubation,  another  to  invasion  and  a 
third  to  the  incidence  of  full  establishment.  The  local  subjective 
symptoms  depend  on  the  inflammation,  its  extension  and  penetration. 
Its  chief  elements  are  pain,  disturbances  of  micturition,  chordee  and 
discharge. 

The  pain  in  severe  cases  is  present  in  the  quiescent  state,  due  to 
the  intensity  of  the  infection;  in  the  act  of  urination,  due  to  the  acidity 
of  the  urine  and  the  denudation  of  epithelium;  in  the  excitement  of 
ere?tion,  due  to  the  infiltration  of  the  corpus  spongiosum  urethrae, 
with  inflammatory  exudate;  and  in  emission,  due  to  the  added  conges- 
tion and  the  alkalinity  of  the  semen  acting  on  the  more  or  less  raw 
epithelium.  The  pain  is  located  in  the  anterior  urethra  and  may 
extend  backward  even  to  the  posterior  urethra  before  the  latter  is 
really  involved,  and  may  be  maximum  at  the  meatus,  ]>oth  by  referred 
pain  process.  It  tra\'els  down  the  urethra,  with  the  stream  of  the 
urine,  until  the  whole  canal  seems  afire.  Pain  during  the  quiescent 
state  is  present  day  or  night,  more  or  less  constant  and  varying  with 
the  severity  of  the  inflammation. 

The  nrinary  disturbances  are  regular  accompaniments  of  the  pain 
and  due  to  the  same  general  causes.  Frequency  may  be  very  trouble- 
some at  first  by  day,  later  by  night,  particularly  if  the  posterior  urethra 
is  even  sympathetically  congested.  The  stream  is  altered  in  size  in 
any  degree  from  normal  to  literal  dribbling,  and  in  form  to  forking, 
twisting  and  spattering,  all  due  to  the  degree  of  edema  and  its  effect 
on  the  course  and  caliber  of  the  canal.  Acute  retention  of  urine  is 
in  intense  cases  often  seen  due  to  muscular  spasm  or  extreme  edema, 
or  both,  in  the  region  of  the  compressor  urethrse  muscle.  Moderate 
bleeding  may  be  present. 

The  chordee  or  chorda  venerea  is  a  troublesome  symptom  commonly 
late  in  the  establishment  ^^■hen  the  corpus  spongiosimi  urethras  is  widely 
and  dee})l\'  infiltrated  and  the  mucosa  greatly  irritated.  Both  these 
factors  stinnilate  erections,  esi)ecially  \\ith  even  a  small  quantit}^  of 
urine  in  the  bladder.  The  corpora  cavernosa  become  turgid,  firm  and 
erect,  while  the  corpus  spongiosum  urethrje,  having  lost  its  extensi- 
bility', elasticity  and  distensibility  temporarily  through  the  disease, 
can  hardly  alter  its  form,  and  therefore  the  attempt  to  stretch  it  causes 
it  to  stand  out  prominently  as  a  thick  cord  along  the  penis,  whence  the 
term  chorda  venerea.  The  pain  proceeds  from  the  great  tension  on  the 
inflamed  tissue  by  the  corpora  cavernosa. 

The  discharge  is  augmented  from  the  mucoi)urulent  moderate  drop 
of  the  invasion  to  a  florid  copious  flow  thickening  from  the  stringy 
condition  in  the  preceding  period  to  that  of  cream  and  changing  in 
color  from  a  watery  white  to  yellow  then  greenish,  staining  the  cloth- 


SYMPTOMATOLOGY  AND  STAGES  41 

ing  of  body  or  bed  with  a  thickish  incrustation  at  the  center,  tliitininj^ 
out  at  the  the  margins  through  the  watery  elements. 

The  systemic  subjective  symptoms  vary  widely,  are  absent  in  mild 
cases  and  pronounced  in  severe  cases,  especially  with  mixed  infection, 
and  are  chiefly  those  of  any  septic  absorption,  anorexia,  constipation, 
anemia,  depression,  prostration,  chills  and  fever  and  insomnia.  They 
need  no  detailed  discussion. 

The  objective  symptoms  should  be  noted  in  regular  anatomical  order 
and  are  due  to  the  inflammation  and  its  accompaniments  in  the  mucosa, 
bloodvessels,  lymph  vessels,  discharge  and  urine. 

Redness  and  edema  affect  the  lining  of  the  foreskin  and  the  glans, 
which  may  become  greatly  excoriated,  wdth  blotches  of  shining  red 
scattered  over  pus-covered  surface.  The  foreskin  as  a  whole  may  be 
almost  densely  infiltrated  and  phimotic.  Lymphangitis  may  early  be 
visible,  palpable  and  tender  but  is  more  often  buried  in  the  edema. 
The  meatus  is  reddened  for  a  variable  zone  over  the  glans,  very  edema- 
tous even  to  eversion  and  sometimes  excoriated.  The  urethra  is  infil- 
trated thick,  inelastic  and  tender  and  often  show^s  its  involved  mucous 
glands  as  shot-like  spots  along  its  course.  The  discharge  is  a  constant 
dropping  of  pus  changing  in  amount,  color  and  consistency  as  just 
noted  under  local  subjective  symptoms.  Owing  to  the  hours  of  sleep, 
the  early  morning  flow  of  pus  represents  the  all-night  accumulation 
and  is,  therefore,  the  most  copious  except  when  severe  disease  dis- 
turbs the  patient  for  frequent  nocturnal  urination.  The  urine  in 
test  glasses  is  very  turbid  in  the  first  and  clear  in  the  second  glass 
in  the  mild  cases  or  slightly  turbid  in  the  severe  cases,  depending  on 
the  thoroughness  with  which  the  urine  washes  the  pus  before  it  into 
the  first  glass.  It  is  obvious  that  a  copious  flow  of  urine  even  in  a 
severe  case  will  tend  to  produce  a  clear  or  nearly  clear  second  glass 
while  a  scanty  flow  will  have  the  opposite  effect.  A  practical  point  of 
importance  therefore  is  to  have  the  patient  call  with  as  much  urme 
in  the  bladder  as  may  be  retained  without  pain — four  or  five  hours' 
urine  is  a  good  supply  wdien  possible. 

The  termination  usually  begins  after  the  establishment  has  run  a 
course  of  about  two  weeks,  rarely  less,  not  uncommonly  more  than 
two  weeks.  It  is  broadly  true  to  say  that  the  average  case  not  char- 
acterized by  severity  or  complications  recpires  about  tw' o  weeks  each 
for  the  incubation  and  invasion  together,  the  establishment  and  the 
termination  each,  in  all  six  w'eeks,  although  the  term  "termination" 
may  thus  only  mean  the  disappearance  of  active  subjective  s%Tnptoms, 
because  very  few  cases  are  without  a  semichronic  or  chronic  "  shred'' 
stage.  As  previously  stated,  chronic  manifestations  will  be  discussed 
separately.  The  local  and  systemic  subjective  SAmptoms  are  a  gradual 
but  unmistakable  decrease,  usually  in  the  reverse  order  of  their  appear- 
ance. The  discharge  becomes  more  watery  and  sometimes  more 
copious  in  this  thin  condition,  then  changes  from  the  green  to  the 
white  mucoid  consistency  and  finally  thickens  into  shreds,  w'hich  may 
be  the  last  of  all  sjTiiptoms  to  disappear.    Chordee  is  quickly  decreased 


42  ACUTE  URETHRITIS 

in  severity  aiul  frequency,  a  fact  which  usually  initiates  the  period  of 
improvement.  Urination  is  much  less  frcciuent  first  at  night,  then 
hy  ilay,  and  is  soon  normal.  Pain  loses  its  agiiravating  (lualities  and 
is  iinally  a  mere  discomfort.  The  general  health  imjiroves,  fever  and 
chills  subside,  appetite  returns,  better  spirits  replace  depression  and 
prostration  and  disappearing  absorption  corrects  the  anemia. 

The  objective  symi)toms  are  a  thimiing  and  decrease  of  the  pus 
from  the  ])urulent  through  the  mucous  and  serous  stages  to  shreds. 
Gonococci  are  progrcssi\cly  fewer  and  harder  to  find  without  and  with 
associated  organisms  in  the  so-called  mixed  infections.  Epithelium 
in  flakes  and  single  cells  is  more  abundant,  the  pavement  type  around 
the  meatus,  rei)lacing  the  cohunuar  tyi)e  of  the  canal  as  a  whole.  All 
test  glasses  of  urine  are  clear,  the  first  alone  contains  heavy  shreds  of 
mucopus,  which  sink,  and  lighter  shreds  and  clouds  of  mucus  which 
float;  both  are  germ-laden  at  first  and  finally  may  be  germ-free  as  the 
case  becomes  cured.  The  author's  seven-glass  test  is  of  great  value  in 
the  diagnosis  of  this  stage.  Its  details  are  given  under  the  subject 
of  Posterior  Urethritis  and  Diagnosis  on  page  75. 

Duration  of  the  Disease. — The  persistence  of  symptoms  varies  with 
the  severity  and  nature  of  the  infection,  the  resistance  of  the  patient, 
the  attention  given  ])y  himself  and  the  treatment  prescribed.  Infec- 
tions in  which  the  gonococcus  is  associated  with  the  pyogenic  organ- 
isms are  apt  to  be  long  cases.  Broadly  speaking,  the  average  case 
lasts  for  six  %veeks,  at  least  so  far  as  the  obvious  symptomatology  is 
concerned;  many  cases,  however,  which  have  given  the  patient  little 
or  no  distress  will  last  as  many  months  before  cure. 

Relapses. — Recrudescence  of  symptoms  is  by  no  means  uncommon 
from  foci  chiefly  in  the  glands  of  the  mucosa,  through  unusual  penetra- 
tion of  the  disease  or  anatomical  complication  of  the  glands,  or  both 
whence  arise  chronic  forms  of  the  disease.  Although  in  very  many 
cases  the  mucosa  as  a  whole  recovers  in  a  much  larger  number  locali- 
ties of  deep  damage  or  destruction  persist  for  many  years  of  life. 


DIAGNOSIS   IN   GENERAL. 

Basis. — Independently  of  whether  or  not  the  lesion  is  nongono- 
coccal or  gonococcal,  the  diagnosis  rests  on  four  elements:  history, 
symptomatology,  physical  signs  with  laboratory  findings  and  treat- 
ment, as  fully  set  forth  in  Chapter  YIII,  on  the  General  Principles  of 
Diagnosis.  The  chief  element  of  diagnosis  and  differentiation  is  the 
recognition  and  demonstration  of  the  infecting  organism.  All  varie- 
ties of  nongonococcal  and  gonococcal  urethritis  may  and  usually  do 
give  a  sexual  history  concerning  which  denials  are  commonly  false- 
hoods. Catarrhal  and  diathetic  urethritis  may  legitimately  have  no 
sexual  history.  In  the  symptomatology  all  forms  agree  as  to  the  kind 
of  s^Tnptoms,  as  has  already  been  fully  discussed.  The  degree  of 
suffering,  however,  is  severest  in  the  suppurative  and  gonococcal  infec- 


DIAGNOSIS  IN  GENERAL  43 

tions,  which  are  almost  indistinguishable  on  this  point.  The  loca- 
tion of  the  symptoms  may  be  meatal  or  i)rei)utial  in  the  cliancroidal 
and  syphilitic  types  but  urethral  in  all  the  other  forms.  'J'he  physical 
examination  serves  to  verify  the  situs  of  the  lesion  and  urinary  study 
in  the  Thompson  two-glass  test  or  the  author's  seven-glass  test  closely 
resemble  each  other.  Pus  is  most  abundant  in  the  sui>purative  and 
gonococcal  forms  and  usually  least  in  the  syphilitic  and  chancroidal 
lesions,  leaving  catarrhal,  diathetic  and  traumatic  urethritis  as  the 
usual  mean.  The  laboratory  findings  must  determine  by  smear  and 
culture  the  infecting  organism  or  other  definite  cause.  Catarrhal 
urethritis  arises  from  the  Micrococcus  catarrhalis  and  diathetic  chiefly 
from  diabetes  and  lithiasis.  Suppurative  urethritis  predominates 
in  the  pyogenic  organisms,  chiefly  the  Streptococcus  and  Staphylo- 
coccus pyogenes,  while  traumatic  may  be  without  pathogenic  germs 
and  abundant  in  exfoliating  epithelium  and  detritus.  Syphilitic 
urethritis  must  show  the  Treponema  pallidum  and  sooner  or  later  a 
positive  Wassermann  reaction,  and  chancroidal  lesions  contain  the 
Bacillus  of  Ducrey.  Gonococcal  infections  must  show  the  diplococcus 
of  Neisser  in  smear  and  culture  and  in  the  severe  and  complicating 
lesions  a  positive  gonococcal  complement-fixation  test.  The  treatment 
serves  to  emphasize  the  correct  findings.  Tonics  are  a  local  and 
systemic  aid  in  catarrh  of  the  urethra.  Relief  of  the  diabetes  and 
lithiasis  reaches  the  diathetic  type  and  removal  of  offending  causes 
demonstrates  traumatic  urethritis.  Antisyphilitic  measures,  surgical 
attention  to  the  chancroid  and  the  means  of  treatment  hereinafter  set 
forth  are  all  indices  of  the  nature  of  infection  in  syphilitic,  chancroidal 
and  gonococcal  disease. 

Differential  Diagnosis. — Gonococcal  urethritis  is  distinguished  from 
the  various  nongonococcal  varieties,  comprising  catarrhal,  diathetic, 
pyogenic,  sj^hilitic,  chancroidal  and  traumatic,  as  most  important. 

Nongonococcal  Acute  Urethritis.  —  General  differentiation  respects 
history,  subjective  and  objective  symptoms,  laboratory  examination 
and  treatment  exactly  as  in  gonococcal  invasion.  The  technic  is  the 
same  for  securing  and  preparing  smears  for  specimens  on  the  micro- 
scopical slide  and  cover  glass  and  on  culture  media  for  groT\i:h  in  the 
laboratory,  whether  from  free  discharge  or  drops  or  only  shreds  in  the 
urine.  The  author's  seven-glass  test  is  available  for  demonstrating 
the  site  of  the  urethra  involved  but  only  in  prolonged  and  complicated 
cases.  The  gonococcal  complement  fixation  test  is  of  value  in  the  same 
general  type  of  disease  for  proving  the  absence  of  gonococcal  absorption, 
but  is  of  no  value  in  mild  forms.  The  Wassermann  reaction  becomes 
of  value  when  syphilis  is  suspected.  The  special  features  of  each  form 
are  outlined  as  follows: 

Catarrhal  Differs  from  GcnccGCcal  Urethritis  in  the  etiological  factors 
stated  in  the  clinical  section,  page  23,  having  a  history  of  low  vitality, 
alcoholism,  frequent  catarrhal  disease  elsewhere  in  the  body  and  per- 
haps many  previous  urethrites  of  gonococcal  or  other  nature.  These 
are  admitted  causes  of  frequent  congestion  in  alcoholism,  hyperacidity 


44  ACUTE  URETHRITIS 

or  hyperalkalinity  of  the  urine,  sexuality  ami  even  infection.  Peri- 
urethral disease,  especially  })rostatism,  nuist  be  remembered.  The  sub- 
jective and  objective  symptoms  rule  as  those  of  a  mild  urethritis  with 
little  discomfort  on  the  i)art  of  the  patient  except  the  nuicopurulent 
discharije  and  include  the  diathesis  or  disease  underlying  the  outbreak. 
In  the  laboratory  there  are  no  gonococci  but  only  the  Micrococcus 
catarrliaJis  and  occasionally  no  organisms  at  all  in  the  simi)le  indolent 
nnicous  discharge.  The  blood  tests  are  negative  for  both  gonococcal 
and  syphilitic  infection.  Treatment  completes  the  diagnosis  in  that 
mucous  membrane  restoratives  internally  administered  and  in  that 
attention  to  the  underlying  diathesis  both  help  more  than  local 
application  which  not  infrc(iuently  increases  the  discharge  and  the 
discomfort.    There  are  no  complications  or  sequels. 

Diathetic  Differs  froDi  Gonococcal  Urethritis  in  having  gout,  rheuma- 
tism, intestinal  toxemia  and  disease,  constipation,  diabetes,  lithiasis 
(gravel)  or  the  strumous  state  prominent  in  the  history.  Many  of  these 
cases  admit  frequent  attacks  of  l)alanitis  in  the  midst  of  such  sickness 
associated  with  the  urethritis.  The  subjective  and  objective  symptoms 
relate  chiefly  to  the  antecedent  attack  of  the  disease  and  to  a  peculiar 
relaxed  mucosa  perhaps  with  discharging  balanitis.  The  discharge 
is  mucopurulent  or  purulent  according  to  severity.  There  is  much 
more  suffering  from  the  antecedent  systemic  disease  than  from  the 
urethritis.  The  laboratory  proves  no  gonococci  present  and  occasionally 
no  organisms  but  much  more  commonly  the  pyogenic  germs  and  others 
common  in  the  urethra  occur.  The  Bacillus  coli  may  be  expected  in 
intestinal  cases.  Both  blood  tests — gonococcal  and  syj)hilitic — are 
negative  and  the  treatment  requires  relief  of  the  underlying  disease  with 
immediate  benefit  to  the  urethritis  which  is  cured  by  mild  local  injec- 
tions or  irrigations  of  astringents  at  suitable  temperature.  The  mucosae 
of  these  subjects  are  so  irritable  that  only  the  simplest  means  should 
be  initiated.     There  are  no  complications  or  sequels. 

Pyogenic  or  Purulent  Differs  from  Gonococcal  Urethritis  in  its  infec- 
tion with  soiled  instruments  or  other  failure  of  asepsis  or  from  a  pus 
focus  elsewhere  in  the  urogenital  tract  in  the  history.  Many  of  these 
cases  are  infected  from  perverted  intercourse  and  show  the  pus  found 
in  the  mouth  while  others  are  evolved  from  normal  intercourse.  The 
subjective  and  objective  symptoms  always  duplicate  in  kind  and  fre- 
quently in  degree  those  of  gonococcal  urethritis,  so  that  every  element 
is  present  except  the  gonococcus  and  all  the  findings  in  the  author's 
seven-glass  test  or  other  multiple-glass  tests  are  the  same.  Fever, 
absorption  and  prostration  are  by  no  means  uncommon  in  many  of 
these  patients.  Laboratory  examination  reveals  a  multitude  of  pyo- 
genic organisms  in  smears  and  culture,  J^ut  no  gonococci.  The  blood 
test  is  likewise  negative  and  reliable  in  the  prolonged  and  complicated 
cases.  Treatment  by  relief  of  the  primary  focus  aids  all  the  local 
measures  already  mentioned  under  the  treatment  of  gonococcal 
urethritis  (page  47).  Not  infrequently  the  same  sequels  and  compli- 
cations occur  as  are  found  in  the  latter  disease. 


DIAGNOSIS  IN  GENERAL 


45 


Syphilitic  or  Charicrons  Differ.s  from  fJonococcal  Urethritis  in  its 
long  incubation,  in  the  history  and  tlic  situation  of  the  lesion  at  the 
meatus  or  inside  the  urethra  and  the  subjective  and  objective  signs 
are  those  of  a  slight  stricture  at  the  meatus  or  fossa  nnvicularis,  a  thin 
discharge  with  a  little  blood  or  pus,  usually  hard  insensitive  lymphatics 
and  rarely  chordee.  Ardor  urinse  may  be  the  sole  complaint.  The 
multiple  glass  tests  show  little  or  no  discharge.  Secondary  lesions  are 
present  in  cases  six  or  eight  weeks  old.  The  typical  chancre  and  usual 
varieties  are  fully  described  under  Balanitis  and  need  not  be  repeaterl 
here.     The  urethroscope,  preferably  the  short  open  end  Chetwood 


Fig.  6. — Phagadenic  paraphimosis.  The  peculiar  destruction  of  the  foreskin  and  glans 
is  apparent.  The  lesion  contained  no  tubercle  bacilli,  no  treponema  pallidum  and  seemed 
to  be  made  up  of  indolent  granulation  tissue  on  pathological  examination.  (Unpub- 
lished case  of  Dr.  C  J.  Seay.) 


tube  (Fig.  145)  or  the  meatoscope  (Fig.  136)  will  often  make  the  diag- 
nosis of  the  lesion  within  the  canal.  In  the  laboratory  the  Treponema 
pallidum  is  recognized  readily  from  the  secretion  of  accessible  lesions, 
but  is  secured  with  difficulty  from  those  within  the  canal.  The  Wasser- 
mann  blood  test  appears  about  the  second  week,  occasionally  earlier. 
The  gonococcus  is  absent  in  the  specimen.  Treatment  locally  and  sys- 
temically  directed  against  the  s^^philis  gives  very  rapid  and  wonderful 
relief  still  further  completing  the  evidence  of  this  special  infection. 

Chancroidal  Differs  from  Gonococcal  Urethritis  in  showing  a  painful 
actively  inflammatory  and  extending  sore  in  its  history,  situated  at  the 


46  ACUTE  URETHRITIS 

meatus  or  within  the  canal  and  causing  the  subjective  and  objective 
syni})toms  of  a  "mouse-eaten"  base,  undercut  and  overhanging  edges, 
inflamed  annexa  and  often  ])ainful  lym])hatic  vessels  and  glands.  There 
are  i)urulent  discharge  and  detritus  whicli  show  in  the  first  glass  of  the 
nniltiple-glass  tests  but  rarely  sufHci(Mitl\'  to  make  a  large  specimen 
turliid.  Artlor  in-in;v  is  common  and  rather  distinct  at  tlie  meatus. 
For  the  laboratory  the  bacillus  of  Dticrey  is  recovered  from  curettings. 
There  is  no  Treponema  pallidiiDi  or  Wassermann  test  and  no  gonococcus 
or  gonococcal  fixation  test  and  the  treatment  with  antiseptic  dressing, 
washing  and  ointment  will  relieve  and  show  the  sim])le  surgical  char- 
acter as  compared  witli  the  chancre  as  a  port  of  entry  of  systemic 
infection.  The  sequel  is  deformity  and  sometimes  stenosis  of  the 
meatus  and  the  com])lication  suppurative  inguinal  adenitis. 

Traiiniotir  Diffei\s-  from  Gonacoceal  Uretliriil,s  in  cmj)hasizing  injury  in 
its  histors^  as  the  cause,  due  to  instruments,  caustics,  heat  or  electricity, 
and  in  having  as  the  subjective  and  objective  symptoms  mild  or  severe 
hemorrhage,  catarrhal  or  purulent  discharge,  marked  ardor  urinje  and 
chordee  according  to  the  nature  and  se\'erity  of  the  excitant.  Instru- 
ments usually  cause  hemorrhage  from  their  mechanical  irritation,  fol- 
lowed by  catarrhal  urethritis  unless  the  instriuuents  were  infected. 
The  other  causes  named  produce  superficial  destruction  of  the  mucosa 
and  ])us  with  all  its  other  symi)toms.  In  the  laboratory  s])ecimen  there 
may  be  no  organisms  at  all  or  the  Micrococcus  catarrhal  is  or  the  ])N'o- 
genic  group  according  to  their  entrance  after  the  traumatism.  There 
are,  therefore,  no  gonococci,  no  Treponema  pallida  and  no  bacilli  of 
Ducrei/,  no  Wassermann  blood  test  and  no  gonococcal  fixation  test 
unless  the  traumatic  urethritis  was  induced  during  the  treatment  of 
any  of  the  other  forms.  Treatment  by  removal  of  the  cause  makes 
the  diagnosis  immediately.  This  should  be  followed  by  the  simpler 
means  of  controlling  the  rest  of  the  reaction.  Severe  cases  have  the 
sequel  of  stricture  as  in  the  author's  case  of  biu-n  of  the  urethra  referred 
to  in  the  chapter  on  Stricture,  and  some  patients  may  have  such 
complications  as  extension  of  the  inflammation  outside  the  urethra  in 
rare  examples. 

Gonococcal  Acute  Urethritis. — General  differentiation  is  exactly  the 
same  as  that  described  for  nongonococcal  acute  urethritis  in  the  earlier 
paragraphs  of  the  subject  of  diagnosis.  The  reader  need  be  reminded 
only  of  the  four  general  factors  of  history,  symptomatology,  labora- 
tory investigation  and  treatment.  Attention  to  these  details  will 
readily  establish  the  diagnosis  and  the  minute  distinctions  from  the 
other  forms  of  acute  m-ethritis  are  already  gi^'en  under  each  such  form 
in  the  paragraphs  on  the  differential  diagnosis. 

It  must  not  be  forgotten  that  the  gonococcus  must  be  searched  for 
in  smear  and  culture,  repeatedly  if  necessary,  and  that  in  severe  or 
conijjlicated  cases  the  gonococcal  complement  fixation  test  must  be 
performed. 


TREATMENT  IN  GENERAL  47 


TREATMENT  IN  GENERAL. 

Gonococcal  Acute  Urethritis. — Prophylaxis. — The  cntin;  subject  of 
prevention  is  treated  'in  the  Chapter  on  the  General  Principles  of 
Treatment  under  the  subheading  Prophylaxis  (page  483),  to  which  the 
reader  is  referred. 

Management. — General  Principles  of  Treatment  in  Chapter  IX,  on 
page  483,  embraces  all  the  procedures  of  management. 

Abortive  Treatment. —  Definition.- — Abortive  treatment  may  be 
regarded  as  immediate  cure  of  the  infection  when  only  the  early  sub- 
jective symptoms  are  present  and  when  the  sole  objective  signs  consist 
of  few  intracellular  and  extracellular  gonococci  with  scattered  des- 
quamated epithelia  and  still  fewer  pus  cells  but  no  fluid  pus  and  no 
true  exudate  of  leukocytes.  Tlie  period  for  the  application  of  the  treat- 
ment in  most  patients  is  preferably  the  first  twenty-four  hours,  rather 
than  the  second  twenty-four  hours. 

Limitations. — The  limitations  arise  from  the  difficulty  of  having 
patients  respect  advice  to  call  at  the  earliest  moment,  or  of  having 
them  rightly  perceive  and  interpret  the  early  symptoms  and  then 
come  for  aid  at  the  golden  moment  of  slight  exfoliation  rather  than 
at  the  later  time  of  exudation  and  discharge. 

Technic. — The  technic  is  threefold,  as  generally  recognized  of  rea- 
sonably reliable  results: 

1.  Application  method. 

2.  Irrigation  method. 

3.  Instillation  and  retention  method  (Ballenger). 

4.  Disapproved  methods,  such  as  dressings,  bougies  and  scrubbing 
of  the  urethra. 

1.  Method  of  a-pplication  implies  one  treatment  as  sufficient  and 
embraces  the  following  steps :  The  patient  evacuates  his  bladder,  thus 
washing  the  urethra  from  behind  forward  tliroughout  under  Nature's 
own  method.  Cleansing  is  further  assured  by  filling  a  150  c.c.  Janet- 
Frank  syi-inge  with  2  or  4  per  cent,  boric  acid  water  at  100°  to  105°  F. 
and  connecting  it  with  a  soft,  short  12  French  catheter  inserted  for  about 
3  inches  into  the  canal  and  then  by  flushing  the  urethra  from  behind 
forward  while  the  patient  is  in  the  recumbent  position.  A  short 
Chetwood  urethroscope  is  passed  into  the  canal,  its  obturator  removed 
and  then  its  sheath  slowly  withdrawn  wliile  a  cotton  applicator  dripping 
with  from  1  to  3  per  cent,  nitrate  of  silver  solution  is  gently  rubbed  on 
the  mucosa,  or  a  few  minims  may  be  left  free  in  the  bottom  of  the  tube 
during  its  deliberate  removal.  Either  application  should  stain  the 
mucosa  a  faint  white.  The  immediate  results  are  sterilization  of  the 
infected  area  and  a  secondary  chemical  urethritis  of  mild  degree  and 
brief  duration  having  a  mucopurulent  or  purulent  discharge  and 
moderate  ardor  urinse  which  steadily  decrease  under  rest  in  bed,  light 
diet,  free  bowels,  cold  locally,  neutral  urine  and  anod}iie  mixtm-es, 
exactly  as  suggested  in  fully  established  cases  of  acute  m-etlu-itis  in  the 


48  ACUTE   URETHRiriS 

followiiiij:  ])nni;j;ra])lis.  A  sootliing  astrinuviit  liand  injection  of  lialf- 
strcngth  ritzniann  is  occasionally  necessary.  The  final  result  is  destruc- 
tion of  the  gonococcus  pro\'ed  by  smear  and  culture  exactly  as  was 
their  presence  recognized  at  the  first  call,  also  a  restored  mucosa  proved 
by  the  absence  of  desquamaticm  and  red  and  white  blood  cells.  The 
A\lu)le  procedure  is  strictly  an  analogue  of  C'rede's  method  of  treating 
the  eye  of  the  newborn  infant.  The  1  per  cent,  silver  nitrate  dropped 
into  the  eye  causes  death  of  any  organisms  present  and  induces  a 
moderate  catarrhal  conjunctiNitis  ^^■hose  irritation  is  allayed  by  local 
a])plications  of  normal  salt  solution  or  boric  acid  water. 

'2.  McfJiod  of  irrHjatiun  requires  one  or  two  treatments  a  day  for 
two  or  three  days  in  accordance  with  the  microscopic  findings  and  the 
activity  of  the  response.  The  patient  passes  his  water  to  remove  all 
])ossible  material  and  the  urethra  is  further  cleansed  by  the  boric  acid 
water  irrigation  of  its  terminal  three  inches,  as  detailed  in  the  method 
of  a]ii)lication.  A  150  c.c.  Janet-Frank  syringe  and  catheter  are  now 
filled  \\\X\\  antiseptic  solutions  at  100°  to  110°  F.  and  flushed  through 
the  meatal  three  inches  of  the  canal  from  behind  forward.  Suitable 
strengths  are  somewhat  stronger  than  those  employed  in  the  irrigation 
method  of  the  early  stage  of  true  exudation  because  the  disease  has 
not  >et  penetrated  deeply.    Examples  are: 

Silver  nitrate  solution 1  in  5000  to  1  in  3000 

ArgjTol  solution 3  per  cent,  to  10  per  cent. 

Protargol  solution 0.5  per  cent,  to  1  per  cent. 

Potassium  permanganate  solution 1  in  2000  to  1  in  1000 

Bichloride  of  mercury  solution 1  in  5000  to  1  in  3000 

The  stronger  solutions  are  best  on  the  first  day  and  the  weaker 
selections  on  the  second  and  third  days,  if  the  reaction  j^ermits.  In 
general  the  earlier  the  case,  the  stronger  and  less  frequent  the  irriga- 
tion within  the  foregoing  limits  which  are  always  safe.  If  the  case  is 
seen  later  but  still  before  the  true  exudation  of  leukocytes  comes  with 
pus  cells  more  numerous,  epithelia  more  frequent,  a  few  red  blood 
cells  and  a  mucopurulent  instead  of  a  mucous  stickiness,  as  is  the  case 
on  the  second  or  third  day,  then  the  irrigations  may  be  a  little  weaker, 
more  copious  and  given  twice  daily.  The  immediate  results  should  be 
disappearance  of  the  gonococci  with  a  secondary  mild  catarrh,  exactly 
as  in  the  method  of  application  in  its  nature  and  treatment  and  the 
end-results  are  complete  restoration  of  the  mucosa.  If  the  gonococci 
persist  after  the  third  day  of  such  treatment  it  may  be  regarded  as  a 
failure  and  the  standard  continuous  method  of  treating  the  disease 
should  be  undertaken. 

The  author's  experience  \\\t\\  social  prophylaxis  duplicates  that  of 
every  other  observer  to  the  ett'ect  that  printed  circulars  or  leaflets  of 
instruction  are  of  benefit  and  that  cases  within  A\'edlock  are  usually 
successful,  especially  among  intelligent  patients  who  after  explanation 
comprehend  and  remember  instructions  and  then  follow  them  out. 
It  is  impossible  to  say  an\thing  worth  vAvXa  about  the  unintelligent. 


TREATMENT  IN  GENERAL 


49 


Janet  Method. — This  is  also  an  irrigation  method  and  is  fully 
described  under  the  standard  treatment  of  urethritis  by  irrigation 
(page  64).  Its  cautions  are  four — which  are  that  the  patient  must 
always  urinate  first,  that  the  irrigation  must  reach  only  the  anterior 
urethra,  that  the  temperature  must  be  moderately  hot,  from  100'^  to 
110°  F.,  and  that  the  concentration  must  be  relatively  weak,  1  in  8000 
to  1  in  4000  watery  solution  of  potassium  permanganate  in  water,  and 
that  the  repetition  should  be  not  more  than  twice  daily. 


Fig.  7. — Assorted  syringes.  A,  triumph  two-dram  asbestos  packed  all  glass  syringe 
for  patient's  use,  with  box,  B;  C,  patient's  urethral  hand  syringe,  with  rubber  bulb 
ejector;  D,  acme  subpreputial  syringe,  with  long  rubber  tip,  glass  barrel,  metal  cap, 
glass  piston  and  cotton  packing;  E,  triumph  all  glass  asbestos  packed,  long  tip  model; 
F,  Hayden  metal  mounted  glass  barrel  leather  packed  cone  point  instillation  syringe, 
with  shoulder  made  fiat  by  the  author  to  prevent  roUing. 

3.  Instillation  and  Retention  Method. — ^Ballenger^  denominates  this 
the  "Sealing-in  Abortive  Treatment  of  Beginning  Gonorrhea,"  seems 
to  be  the  originator  of  it  and  claims  that  "  we  have  probably  adminis- 
tered 4500  of  these  treatments  during  the  past  four  years  and  have 
never  seen  a  stricture  or  any  other  harmful  results  produced  b}^  them." 
Its  basis  of  success  is  application  during  the  first  twenty-four  to  forty- 
eight  hours  of  the  disease  of  5  per  cent,  freshly  prepared  arg;yTol  solu- 
tion once  daily  for  five  days  with  retention  for  at  least  six  hours  by 


1  Genito-urinary  Diseases  and  Syphilis,  1913,  pp.  15-21. 


50 


ACUTE  URETHRITIS 


means  of  a  collodion  cap  ni)on  the  ijlans.  The  organisms  are  reached 
and  destroyed  tliroughout  the  length  and  depth  of  the  infected  area 
at  this  early  stage  and  gonococci,  staphylococci,  colon  bacilli  and 
psendogonococci  are  equally  well  destroyed.  No  harm  to  the  intiam- 
niation  occurs  if  the  method  fails.  Its  basis  of  failure  is  intercourse 
during  the  incubation  period,  a  prolonged  incubation,  early  follicular 
abscess  or  in^'olvement,  and  any  form  of  other  treatment  such  as 
irrigation,  instrumentation  and  deep  injection,  because  such  invite 
extension  of  the  infection  beyond  the  zone  benefited  by  the  sealed-in 
instillation. 


Ae.    Oor.oo.    Ant-Poot.   nrcthrltls. 


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Fig.  8 


In  the  technic  the  patient's  bladder  must  be  empty  and  kept  as  little 
active  as  possible  by  greatly  limited  fluids  and  food  during  the  period 
of  retention,  which  is  about  six  hours  each  day  for  five  days.  In  the 
recumbent  position,  the  glans  penis  is  carefully  cleaned,  dried  and 
surrounded  with  a  sterilized  towel.  With  a  cone  point  urethral  syringe 
25  minims  and  no  more  of  a  5  per  cent,  watery  solution  of  argyrol  are 
gently  instilled  into  the  anterior  urethra  in  all  cases  except  those 
which  are  seen  on  the  second  or  third  instead  of  the  first  dav.    In  these 


TREATMENT  IN  GENERAL 


51 


patients  the  medicine  is  gently  massaged  backward  in  order  to  provide 
contact  with  the  more  extensive  infection  of  the  mucosa.  As  the 
syringe  is  removed,  and  while,  the  massage  is  i)erformed  if  dorif;,  the 
meatus  is  compressed  shut  from  side  to  side,  dried  carefully  with 
the  towel  and  then  covered  with  a  plug  of  noncontractile  collodion 
(U.  S.  P.),  which  dries  while  the  urethra  is  still  kept  closed. 

The  patient  is  now  allowed  to  go  home  and  to  observe  the  following 
strict  precautions:  abstinence  from  violent  exercise,  fluid  and  food, 
except  in  moderation,  and  sexual  stimulation.     At  the  end  of  about 


Char 

t   4. 

1 

1 

' 

Fig.  9 


six  hours  the  collodion  plug  is  removed  by  softening  it  with  acetone 
or  by  pulling  it  off  by  means  of  the  cotton  handle  secm'ed  at  one  edge 
but  always  Siway  from  the  meatus  because  if  the  cotton  handle  reaches 
the  meatus  it  will  drain  off  the  arg}Tol.  Mter  the  plug  is  removed, 
the  patient  drinks  copiously  of  alkaline  water  so  as  to  flush  out  the  canal 
with  neutral  urine  and  to  relieve  the  chemical  and  mechanical  hrita- 
tion  essentially  secondary  to  this  procedure.  The  following  day  for  a 
brief  period  he  takes  little  fluid  or  food  so  as  to  limit  the  excretion  of 


52  ACUTE  URETHRITIS 

iirine  and  so  as  not  to  interfere  with  the  treatment  and  then  reports 
for  the  second  appheation.  This  proce(hn-e  is  rej^eated  once  a  day  for 
five  days.  The  presence  of  the  gonococcus  at  this  time  usually  indi- 
cates failure  and  resort  to  the  standard  methods  of  treatment.  AVhile 
tlie  arg\Tolis  retained  it  is  well  to  have  the  patient  wear  a  light  cotton 
dressing  for  the  discovery  of  leakage  if  the  collodion  breaks  or  loosens. 
Beginning  the  treatuient  with  .1  per  cent,  solution,  gradual  decrease  in 
the  strength  to  :>  or  2  ]ier  cent,  may  he  followed  esi)ecially  if  the  chemical 
reaction  seems  acti\"e.  Relapses  of  the  urethritis  after  the  five  days 
of  treatment  are  over  mean  failure  of  penetration  or  extension  of  the 
arg^^'ol  to  coincide  with  the  zone  of  infection  and  may  be  checked,  if 
not  violent,  by  a  repetition  of  the  jirocedure  before  the  standard  treat- 
ment is  undertaken.  The  technical  difficulties  of  this  method  are  not 
insurmountable  and  Ballenger  recommends  that  the  beginner  acquire 
skill  by  trying  it  on  chronic  cases  which  are  in  no  wise  ad^'ersely 
influenced  l\v  it. 

Aftertreatmcni — These  measures  in  Ballenger's  method  are  only 
observation  to  see  that  the  medication  has  not  induced  a  chemical 
urethritis  Avhich  should  be  treated  as  shown  under  the  subject  of  Trau- 
matic Urethritis  (page  305) . 

Cure. — This  term  iuA'oh'es  relief  of  the  infection  and  therefore 
freedom  from  any  of  its  developments. 

4.  Disapproved  Abortive  Methods  are  the  urethral  dressing,  as  recom- 
mended by  Boureau/  and  urethral  bougies.  Both  these  are  medicated, 
but  the  cotton  or  gauze  in  the  former  and  the  gelatin  in  the  latter 
act  as  foreign  bodies,  irritate  the  mucosa  and  excite  rather  than  check 
the  infection.  Scrubbing  of  the  urethra  with  a  brush,  such  as  is  used 
for  tubes,  suggested  by  Huguet,^  only  denudes  the  epithelium,  which 
is  exactlv  ^^■hat  the  gonococcus  does  and  therefore  only  leads  to  its 
rapid  extension,  although  the  theory  was  that  of  affording  ])enctra- 
tion  of  antiseptics  to  the  deeper  laj'ers  of  epithelium  into  which  this 
organism  penetrates. 

Curative  Treatment. — Classification. —As  in  e^'ery  chapter  concerned 
with  clinical  features  and  complications,  anterior  and  posterior  ure- 
thritis \\\\\  be  separately  considered  and  the  gonococcal  infection  will 
be  regarded  as  the  type  and  other  forms  will  be  described  thereafter, 
with  their  variations. 

Case  Records. — Xo  case  may  be  comprehensively  and  systemically 
followed  without  office  records.  The  author's^  history  charts  are  shown 
in  Figs.  8  and  9.  Symptoms  and  remedies  appear  in  the  left-hand 
column,  dates  are  at  the  top  of  the  small  columns  and  progress  is 
algebraically  indicated  in  them. 

Methods  are  two — (1)  the  conservative  expectant  or  antiphlogistic 
method,  A\hich  is  the  older,  and  (2)  the  irrigation  or  Janet  treatment, 
which  is  the  newer.    Each  has  its  strong  advocates. 

'  Moscow  International  Congress,  1897.  '  Thfese  de  Paris,  1888. 

5  Tr.  Am.  Urol.  Assn.,  1913,  p.  163. 


TREATMENT  IN  GENERAL  53 

Anterior  Gonococcal  Acute  Urethritis. — Conservative  Method. — 'i'his 
treatment  is  also  called  expectant  because  the  various  stages  of  the  dis- 
ease are  awaited  in  their  development  before  additional  measures  are 
adopted,  likewise  antii)hlogistic  because  it  gives  particular  attention 
to  the  local  and  systemic  febrile  characters  of  the  lesion.  Its  aims  in 
general  are  those  of  treating  the  acute  and  early  establishment  diiVcr- 
ently  from  the  subacute  later  and  declining  period,  to  the  degree  that 
in  the  former  no  antiseptics  are  locally  applied  to  the  urethra  by  .hand 
injection  or  irrigation  while  these  measures  feature  the  latter  period. 
The  advantages  are  that  it  is  the  method  of  least  disturbance  of  Nature's 
processes  concerning  the  inflammation,  the  plan  of  fewest  complica- 
tions induced  by  overtreatment,  the  procedure  of  greatest  safety  for 
the  inexperienced  nonspecialist,  the  treatment  of  least  meddling  and 
the  management  of  fullest  respect  for  the  course  and  stages  of  the 
disease,  with  minimal  interruption  and  interference.  Its  disadvantages^ 
are  delayed  antiseptic  attack  on  the  gonococci,  the  relatively  slower 
though  more  gentle  uncomplicated  course  of  the  disease  and  the  dis- 
satisfaction of  many  patients,  with  the  fact  that  "nothing  is  being 
done"  during  the  first  two  weeks. 

Stages  of  incubation  and  invasion  are  managed  as  set  forth  in  the 
paragraphs  on  Prophylactic  and  Abortive  Treatment  on  page  47,  and 
will  not  be  further  discussed  here. 

Stage  of  establishment  requires  attention  to  the  general  details  of 
management  and  internal  and  local  medicinal  measures. 

The  dressing  of  choice  is  a  piece  of  gauze  about  6  inches  square,  with 
a  small  hole  cut  at  its  center  through  which  the  glans  penis  is  passed 
after  retraction  of  the  foreskin.  With  the  gauze  resting  in  the  corona 
the  foreskin  is  replaced,  thus  leaving  a  loose  apron  which  does  not  im- 
prison the  discharge  within  the  urethra.  The  preliminary  and  final 
adjustments  of  this  dressing  are  shown  in  Figs.  10  and  11.  This  dress- 
ing should  not  be  allowed  to  adhere  to  the  meatus  and  glans  and  should 
be  changed  approximately  at  every  urination,  at  least  e^'ery  t^'o  or 
three  hours  by  day  and  once  or  twice  at  night  during  wakefulness. 
In  the  circumcized  and  patients  without  average  foreskins  a  larger 
piece  of  gauze  may  be  prepared  with  a  hole  through  which  the  penis 
passes  freely,  whose  margins  are  pinned  on  each  side  of  the  penile 
opening  in  the  suspensory  bandage.  The  wearing  of  a  cotton  plug 
inside  the  foreskin  and  against  the  meatus  is  to  be  condemned 
because  it  holds  the  discharge  inside  the  urethra  and  directly  defeats 
Nature's  aim  at  cure  of  the  disease  by  the  free  production  and  .dis- 
charge of  pus  and  gonococci  which  by  retention  are  favored  in  their 
characteristic  powers  of  penetration.  The  patient  cannot  understand 
this  result  too  well.  So-called  "  gonococcal  penUe  bags"  are  not  advised 
unless  several  are  purchased  so  that  only  clean  ones,  free  of  dry  or  moist 
pus,  are  in  use  and  also  unless  they  are  large  enough  and  hung  lou- 
enough  to  prevent  the  meatus  from  resting  on  the  cotton  at  the  bottom 
and  thus  again  being  plugged.    Muslin  or  linen  bags  do  not  sweat  the 


54 


ACUTE   URETHRITIS 


l)art8  as  much  as  ruhbcr  ones.    It  ij;  wi'U  known  that  hi>at  and  moisture 
favor  nuiltiplication  of  orijanisms. 

rroi)hyhixis  is  important  and  in  this  coiUK'c'tion  (UlVcrs  from  that 
introducinu'  this  chaiJter  and  is  conc-crnod  witii  the  eyes  of  the  j^atient 
and  infection  of  innocent,  associates.  The  eyes  are  guarded  from  con- 
tamination by  the  simple  rule  of  great  cleanliness  of  the  hands,  especi- 
ally the  finger-nails,  which  should  be  carefully  cleaned  whenever  the 
patient  uses  the  toilet  or  in  any  way  treats  his  dis(>ase.  A  curious  error 
to  be  corrected  is  that  by  ^^■hich  many  patients  wash  their  hands  before 
they  adjust  their  clothing,  which  is  at  least  theoretically  always  con- 
taminated, and  tlioreforc  attain  renders  their  fin<::crs  dangerous  to  the 


Fig.  10. — Gauze  dressing  during  the  acute  stage;  the  glans  is  passed  tlirough  the  gauze 
to  the  sulcus  with  the  foreskin  fully  retracted. 


eyes.  The  hands  should  be  washed  last  after  every  other  detail  has  been 
provided  for.  The  patient's  associates  are  protected  by  having  him, 
as  far  as  possible,  sleep  alone  and  use  separate  toilet  articles,  especially 
such  as  come  into  contact  with  his  hands,  body  and  face,  notably 
towels,  wash-cloths,  handkerchiefs,  napkins  and  the  like.  All  dressings 
should  be  placed  in  cheap  bags  or  envelopes  and  burned — a  plan  which 
permits  the  business  man  to  seal  his  dressings  up  until  he  reaches  home 
for  their  destruction.  Nothing  that  is  insoluble  in  water  should  ever 
be  thrown  down  a  toilet,  so  that  such  disposal  of  cotton  and  gauze 
should  never  be  attempted  because  they  stop  up  plumbing  work. 
Similarly,  sja-inges  and  other  appliances  should  be  kept  apart,  and  the 


TREATMENT  IN  GENERAL 


55 


best  type  of  the  former  is  now  sold  in  wooden  boxes,  which  keep  them 
away  from  the  lining  of  pockets  and  handkerchiefs  therein  (Fig.  7, 
AandB). 

Management. — This  topic  is  discussed  and  detailed  in  Chapter  IX, 
on  the  subject  of  General  Principles  of  Treatment  on  page  483. 

Leaflets  and  pamphlets  of  instruction  such  as  the  following  cover  all 
this  ground  clearly.  It  has  been  used  by  the  author  for  many  years  in 
clinical  practice  and  is  founded  on  one  by  the  late  FoUen  Cabot.^  In 
private  practice  a  reprint  of  the  author's  article  is  given  to  patients, 
"Instructions  on  Gonorrhea. "2 

Medicinal  measures  include  those  for  local  and  systemic  adminis- 
tration and  for  pathologic  and  symptomatic  indications. 


Fig.  11. — Represents  the  gauze  gathered  in  front  of  the  glans,  and  when  thick  for  a 
copious  discharge  held  closed  for  receiving  the  pus.  The  foreskin  is  shown  pushed  for- 
ward over  the  glans  and  the  gauze  to  hold  it  in  place. 

Local  subjective  symptoms  have  been  given  in  the  cHnical  sections 
(page  34)  as  pain,  urinary  disturbances,  chordee  and  discharge.  The 
following  suggestions  apply  to  each  in  turn: 

The  pain,  by  local  treatment,  is  relieved  by  hot  baths  to  withdraw 
congestion  from  the  urethral  mucosa,  consisting  in  penile,  sitting  and 


1  The   Importance  of   Systematic    Education  of   Hospital  and    Dispensary  Patients 
Afflicted  with  Venereal  Disease,  1907. 

2  Long  Island  Med.  Jour.,  October,  1907,  i,  411. 


56 


ACUTE  URETHRITIS 


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TREATMENT  IN  GENERAL  57 

even  })ody  baths,  of  a  temperature  to  j>roduce  redness  of  the  skin 
and  contmued  fifteen  to  thirty  minutes  until  pain  is  alleviated.  When 
a  special  tub  is  not  available  the  effect  of  a  sitting  bath  is  obtained  by 
drawing  twelve  inches  of  hot  water  in  a  common  tub  anrl  ])y  having  the 
patient  sit  in  the  water  with  his  legs  extended.  All  baths  should  be 
taken  at  night,  so  that  the  patient  may  step  from  the  tub  into  bed, 
othenvise  chilling  of  the  surface  will  augment  the  disease  and  perhaps 
add  a  severe  cold.  When  heat  fails,  cold  in  the  form  of  an  ice-bag 
applied  to  the  pubic  region  or  perineum  or  of  a  wet  dressing  kept  on  the 
penis  is  of  service.  Through  internal  administration  neutral  copious 
urine  avoids  the  pain  caused  by  acidity,  tends  to  limit  the  inflammation, 
so  that  chordee  may  be  escaped,  and  flushes  out  the  discharge.  Litmus 
paper  must  be  used  to  show  neutrality.  The  following  formulas  are  of 
service  in  neutralizing  the  urine  and  increasing  its  flow  in  addition  to 
the  various  drinks  stated  under  that  heading: 

I^— Bicarbonate  of  soda,  in  tablet  or  powder,  grains  5  to  20  three  times  a  day. 

I^ — Bicarbonate  of  potash 30  grammes  (1  ounce) 

Tincture  of  hyoscyamus 15  grammes  (^  ounce) 

Distilled  water  up  to 240  grammes  (8  ounces) 

Mix,  make  a  solution  and  mark: 

One  tablespoonful  in  a  small  glass  of  water  three  times  a  day,  two  hours  after  eating. 

I^ — Salicylate  of  soda 0.75  grammes  (12  grains) 

Bicarbonate  of  soda 0.75  grammes  (12  grains) 

Benzoate  of  soda 0.75  grammes  (12  grains) 

Mix,  make  a  powder  and  mark: 

Take  1  powder  mth  a  glass  of  water  three  times  a  day,  two  hours  after  eating. 

Such  combination  may  be  directed  as  a  powder  three  times  a  day,  or 
with  any  one  or  two  of  the  ingredients  omitted,  it  is  very  serviceable, 
or  it  may  be  made  into  a  solution  with  a  tablespoonful  dose.  ^Nlilk, 
either  ordinary,  predigested  or  fermented,  and  alkaline  mineral  waters, 
such  as  Vichy,  are  very  acceptable  and  useful  either  alone  and  separate 
or  mixed  in  equal  or  other  proportions. 

Avoidance  of  sexual  excitement,  direct  and  indirect,  by  eliminating 
its  congestion  reduces  the  pain  of  erection  and  of  ejaculation  and 
blood-letting  in  the  form  of  several  leeches  applied  to  the  perineimi  but 
not  to  the  penis  or  scrotum  may  be  employed  in  extreme  pain  of  con- 
gestion and  edema,  with  obstruction  and  retention  of  urine. 

Urinary  disturbances  are  frequenc}^  altered  stream  and  acute  reten- 
tion. Frequency  is  benefited  by  limiting  the  intake  of  fluids  to  moder- 
ation, so  that  lu^ination  occurs  not  more  frequently  than  once  every 
hour  or  preferably  every  two  hours.  Constipation  by  congesting  the 
prostate  may  also  cause  frequency  without  the  presence  of  posterior 
urethritis.  Altered  stream  is  usually  due  to  edema  and  is  benefited  by 
hydrotherapy — penile,  hip  and  body  baths — in  the  earlier  periods  and 
in  the  later  periods  by  properly  selected  and  applied  hand  injections. 
Acute  retention  is  dealt  with  in  its  own  section  (page  78),  but  in  mUd 
forms  is  released  by  the  hot  baths  and  anod^^les  and  antispasmodics,  of 


58  ACUTE  URETHRITIS 

which  none  are  better  than  Magendie's  solution  of  morphin,  minims  6 
to  S,  hy])oderniieally,  for  definite  eases,  or  codein  suli)hate,  grain  ^  to  1, 
by  mouth,  every  fi\e  hours,  or  an  o])ium  suppository,  grain  \  to  1,  once 
or  twice  a  day.  The  advent  of  intense  retention  requires  relief  of  the 
bladder  by  suprapubic  aspiration  with  a  long  medium  caliber  needle. 
Catheterization  in  any  form  whate\"er  is  absolutely  forbidden,  for  fear 
of  infecting  the  bladder. 

The  chordee  is  possibly  pre^•ented  by  all  the  means  suggested  for 
allaying  inflannnation  and  edema  in  the  prevention  of  pain,  of  which 
chordee  may  be  regarded  as  one  manifestation.  Cleanliness  of  the 
foreskin,  freedom  from  tight  gauze  dressings  about  the  glans,  proper 
fittuig  of  the  suspensory  bandage,  regular  easy  evacuation  of  the 
bowels,  rest  and  quiet  in  avoidance  of  the  congestion  of  exercise  and 
that  of  errors  in  diet,  drink  and  sexuality,  and  finally  the  use  of  light 
and  loose  sleej^ing  apparel  and  bed-clothing,  all  remove  sources  of  reHex 
disturbance  and  irritation,  and  with  these  the  tendency  to  partial  or 
complete  erection.  It  is  alleviated  by  hot  baths  applied  to  the  penis 
and  hips  as  decongestants  and  sometimes  by  the  ice-bag  when  heat 
fails.  Of  sen-ice  are  the  opium  suppository,  grain  |  to  1,  before  retiring, 
and  anodynes,  such  as  the  bromide  of  camphor,  grains  10  to  15,  at 
night,  or  smaller  doses  three  times  daily;  codein,  grains  |  to  1,  before 
bedtime,  or  less  at  regular  diurnal  intervals,  and  the  bromide  of  soda 
and  bromide  of  potash,  grains  10  to  20  each,  an  hour  before  bedtime. 
Antipyrin,  with  or  without  opium  ])ro(lucts,  l)oth  in  moderation,  are 
recommended  such  as: 

I^ — Autipyrine 0.2  to  0.3  gramme  (3  to  5  grains) 

Codein  sulphate 0.016  to  0.032  gramme  (grains  ^  to  |) 

Mix,  make  one  pill  and  mark: 

One  pill  three  times  a  day  or  two  or  three  pills  before  retiring. 

I^ — Bromide  of  potash 1 .0  gramme  (15  grains) 

Bromide  of  soda 1  gramme  (15  grains) 

Distilled  water  up  to 8  c.c.      (  2  drams) 

Mi.\,  make  a  solution  and  mark : 

Two  teaspoonfuls  at  night  before  retiring  or  one  three  times  a  day  in  a  half-glass  of 
water,  two  hours  after  eating. 

Phenacetin  in  doses  of  0.3  to  0.6  gramme  (grains  5  to  10),  once  or  twice 
a  day,  is  a  good  anodyne  and  circulatory  sedative,  and  the  author  has 
had  excellent  results  in  sthenic  patients,  with  tablet  triturates  contain- 
ing from  ]  to  1  minim  of  fluidextract  of  aconite,  every  one  or  two  hours, 
until  the  slightest  sign  of  physiological  action,  as  sweating,  relaxation 
or  tickling  of  the  finger-tips  or  tongue  appears  or  until  three  or  four 
doses  have  been  taken.  Inhibition  of  the  erection  is  sometimes  possible 
by  grasping  the  thighs  near  the  groin  over  the  adductor  muscles  in 
which  the  crural  branch  of  the  genitocrural  nerve  1  ies  imtil  slight  pain 
is  ])roduced.  Thus  inhibitory  impulses  are  set  up  in  the  genital  branch, 
which  often  checks  the  erection  at  its  very  onset. 

The  discharge  in  the  acute  period  is  left  alone  locally  in  the  expectant 
treatment  until  the  severity  of  the  symptoms  begins  to  decHne,  but 


TREATMENT  IN  GENERAL  59 

is  influenced,  of  course,  by  the  general  management  and  methods  just 
described.  Therefore  the  local  measures  against  this  symptom  are 
noted  in  later  paragraphs. 

Systemic  subjective  symptoms  have  been  listed  elsewhere  (page  34), 
as  anorexia,  constipation,  anemia,  depression,  prostration,  chilliness, 
fever  and  insomnia,  varying  in  severity  so  that  in  mild  cases  they  are 
hardly  discernible.  Anorexia,  constipation  and  anemia  are  all  benefited 
by  good  diet  and  rhubarb  and  soda  mixture  (U.  S.  P.)  in  1  to  2  teaspoon- 
ful  doses  three  times  a.  day.  The  soda  is  of  benefit  to  the  acid  urine, 
but  the  rhubarb  may  irritate  the  inflammation.  In  such  event  simple 
bitters  or  digestants  and  cathartics  are  required.  This  old-time  remedy 
is  a  good  corrigent  of  the  digestive  disturbance  of  many  of  the  other 
medicines  required  by  the  symptoms.  Depression  and  prostration  call 
for  moral  assurance,  establishment  of  confidence  of  relief  and  either 
mild  stimulation,  with  strychnin,  for  example,  or  sedation  with 
bromides.  Chilliness  and  fever  suggest  rest  in  bed,  evacuation  of  the 
bowels,  opening  of  the  skin,  light  diet  and  Dover's  powder,  grains  5  to 
10,  at  night,  and  insomnia  is  reached  with  the  hot  or  cold  bath  and  very 
mild  hypnotics,  of  which  none  is  to  be  preferred  to  increase  of  the 
bromides,  perhaps  already  being  administered  for  the  pain  and  chordee. 

Overmedication  may  easily  ensue  upon  too  much  attention  to  these 
subjective  sjinptoms,  which  commonly  last  a  few  days  at  the  most  and 
disappear  under  nature's  own  processes.  Intense  infection,  however, 
may  require  great  judgment  in  these  as  well  as  other  particulars. 

Objective  local  symptoms  have  been  detailed  in  other  pages  as  red- 
ness, edema  and  infiltration  of  the  meatus,  foreskin  and  urethra, 
lymphangitis  and  discharge.  Eedness  and  edema  are  not  preventable, 
but  greatly  benefited  by  cleanliness  and  all  the  measures  previously 
described  for  the  pain  and  congestion.  Lesions  of  the  foreskin  may 
be  prevented  by  prophylactic  measiu-es  of  cleanliness  and  antiseptic 
washing.  Lymphangeitis  and  l}Tiiphadenitis  commonly  rest  on  lesions 
of  the  foreskin,  such  as  phimosis,  paraphimosis,  excoriating  balano- 
posthitis  and  the  pocketing  of  pus.  Soap  and  water  and  antiseptic 
cleansing  are  preventives  if  the  foreskin  is  retractable,  followed  by 
the  application  of  drying  powders,  of  which  none  are  better  than 
various  combinations  of  thymol  iodid,  boric  acid  and  bismuth  sub- 
gallate.  If  the  foreskin  is  not  retractable,  then  subpreputial  irrigations  as 
described  on  pages  86  and  97,  under  the  complication  phimosis  and  hand 
injections  of  mild  antiseptics  are  indicated.  Tincture  of  iodin  painted 
lightly  over  the  inflamed  trunks  and  glands  is  of  service  if  applied  in 
the  morning,  as  in  the  evening  the  irritation  may  cause  wakefulness. 

Discharge  is  so  largely  a  local  condition  that  it  is  hardly  influenced 
directly  by  internal  medication.  The  urinary  antiseptics,  therefore, 
largely  fail  against  the  gonococcus  because  the  organism  is  beneath 
the  surface  of  the  mucosa,  where  it  does  its  harm  and  from  which  it  is 
cast  off  by  the  exfoliation  of  epithelia  and  the  diapedesis  of  leukocnes 
in  the  formation  of  pus.  These  urinary  cleansing  agents  are  available 
only  in  the  kidneys,  where  the  pus  is  present  at  the  point  of  secretion 


•  lO  ACUTE  URETHRITIS 

of  the  urine  or  in  the  pelves  of  the  kidneys  and  the  bhuhler,  wliere  for 
a  relatively  long  time  they  are  in  contact  with  the  infecting  organisms, 
hut  in  the  urethra  the  outfioAv  of  urine  is  so  brief  that  the  contact 
between  the  two  is  insufheient.  The  following  are  the  antiseptics 
usually  employed: 

R — Hexanicthylenamin 0.5  gramme    (7.5  grains) 

Alone  or  combined  with 

Sodium  benzoate 0.5  gramme    (7.5  grains) 

Distilled  water  up  to 4.0  grammes  (1  dram) 

Mix,  make  a  solution  and  mark: 

One  teaspoonful  in  a  iialf-glass  of  water  every  four  hours  or  three  times  a  day,  two 
hours  after  eating. 

The  benzoate  of  soda  is  an  adjuvant  of  the  germicidal  action  and  a 
corrigent  of  the  irritating  action  of  the  hexamethylenamin. 

1$ — Salol         0.3  gramme    (5  grains"! 

Mark:  One  tablet  or  powder  witli  a  glassful  of  water  every  four  hours. 

I^ — Sodium  salicylate 0.3  gramme    (5  grains) 

Distilled  water  up  to 4.0  grammes  (1  dram) 

Mix,  make  a  solution  and  mark: 

One  teaspoonful  in  a  half-glass  of  water  every  four  hours  or  three  times  a  day,  two 
hours  after  eating 

Benzoate  of  soda  or  salol  may  be  added,  either  or  both,  if  desired. 

The  stage  of  decline  is  marked  by  definite  subjecti^'e  relief  and  objec- 
tive impro\-ement  in  all  symptoms,  especially  that  of  the  urine  in  the 
multii)le-glass  tests.  In  a  word,  it  is  the  time  of  i)rogressing  quies- 
cence and  beginning  control  of  the  infection  by  nature's  own  processes. 
It  is  also  the  preferred  period  for  instituting  local  treatment  of  the 
urethra  as  a  diseased  anatomical  entity. 

The  local  measures  are  either  hand  injections,  office  irrigations  or 
both  combined  and  are  employed  in  the  urethra  only  in  the  declining 
stage,  when  both  the  suffering  and  the  pus  are  definitely  less  acti\'e, 
which  means  toward  the  end  of  the  second  to  the  third  Aveek  in  mild 
cases  and  of  the  tliird  to  the  fiftli  week  in  severe  cases.  It  is  the 
symptoms  and  not  the  elapsed  time  which  determine,  and  there  must 
be  fewer  gonococci,  pus  and  exfoliated  epithelial  cells  under  the  micro- 
scope, and  glass  1  of  urine  must  be  less  densely  turbid  and  glass  2 
clear  or  nearly  clear  respectiA'ely  in  the  mild  and  marked  cases. 

The  methods  are,  as  stated,  three:  (1)  Hand  injections,  by  which 
the  i^atient  with  a  small  syringe  medicates  his  own  urethra;  (2)  irri- 
gations, with  catheter  and  bladder  s>Tinge,  by  w'hich  the  physician 
from  behind  forAvard  flushes  the  urethra;  and  (3)  both  hand  injections 
and  irrigations  combhied,  because  it  is  rarely  possible  to  have  the 
j)atient  call  with  sufficient  frequency  to  have  the  irrigation  alone  of 
terminal  value.  The  local  action  is  antiseptic,  astringent  and  stimu- 
lating, which  succeed  each  other  as  the  case  progresses,  so  as  to  cor- 
respond with  the  periods  of  infection  with  gonococci  numerous,  then 
that  of  declining  symptoms  and  mucopurulence,  Avith  fcAA^er  or  absent 


TREATMENT  IN  GENERAL 


61 


gonococci,  and  finally  that  of  more  or  less  indolent  mucous  discharge, 
constituting  the  terminal  period  and  requiring  stimulation  for  cure.  The 
indications  are  therefore:  (1)  To  interfere  with  and  depreciate  least 
Nature's  own  processes  of  repair  dm-ing  ull  i)eriods  of  the  disease;  (2) 
to  promote  and  stimulate  most  Nature's  defensive  properties  against 
the  organisms  and  their  toxins;  and  (3)  to  determine  the  limits  of 
beneficial  influence  of  treatment  as  to  the  disease  process  as  a  whf>Ie. 
If  these  three  elements  may  be  met  then  rational  treatment  will  be  the 
result. 


Fig.  12. — Anterior  irrigation.  The  patient  holds  tlie  basin  and  his  penis  while 
the  Janet-Frank  syringe  rests  on  the  basin  and  is  connected  with  the  catheter  passed  into 
the  urethra  to  tlie  desired  distance  and  held  from  slipping  by  the  forceps.  The  layer  of 
gauze  thrown  over  the  penis  and  catheter  prevents  all  splash  and  spatter  and  conducts 
the  return  flow  into  the  basin.     (Original.) 

Hand  injections  have  very  definite  restrictions  and  service.  The 
preliminary  instructions  are  contained  in  the  following  rules  in  the 
author's  article  published  elsewhere:^ 

First,  always  urinate  before  taking  the  injection,  in  order  to  wash 
as  much  pus  from  the  m-ethra  as  possible. 

Second,  never  use  force  in  taking  the  injections,  but  rather,  on  the 
contrary,  be  as  gentle  as  possible. 

Third,  never  use  a  syi'inge  that  does  not  work  smoothly,  because 
a  "kicking"  syringe  prevents  gentleness. 


1  Pedersen,  V.  C:  Instruction  on  Gonorrhea,  loc.  cit. 


62 


ACUTE  URETHRITIS 


Fourth,  never  use  more  than  one  syrini;vfiil  at  one  iujcetion  unless 
specially  ordered  by  the  doctor. 

Fifth,  fill  the  syrin<:;e,  hold  it  tightly  against  the  mouth  of  the  penis 
and  .gently  fill  the  ])a.ssage  until  it  feels  as  full  as  it  does  when  urine  is 
passing  thnnigh  it.  In  other  Avords,  no  pressure  greater  than  Nature's 
own  during  the  act  of  urination  is  either  necessary  or  desirable. 

Sixth,  hold  the  injection  in  five  or  ten  minutes  by  the  watch  (time  to 
be  specified  by  the  physician). 


Fig.  13. — Anterior  instillation.  The  patient  holds  the  basin  beneath  and  free  of  his 
penis,  which  rests  against  the  scrotum.  The  hands  of  the  operator  support  the  syringe 
and  catheter,  with  the  forceps  against  slipping  during  the  instillation.    (Original.) 


Seventh,  after  cure,  never  loan  the  syringe  to  anyone  else  but  rather 
destroy  it  in  order  to  avoid  poisoning  anyborly  Avith  it. 

Eighth  (omitted  from  the  article  quoted),  beghi  with  one  or  two 
injections  a  day  as  directed  by  the  doctor  and  do  not  increase  the 
number  of  injections  without  his  knowledge  or  orders. 

These  eight  simple  rides  should  be  printed  on  a  slij)  of  paper  and 
handed  to  the  patient,  with  suitable  explanations  and  injunctions  when 
the  proper  time  for  beginning  this  treatment  is  at  hand.  If  they  are 
included  in  the  original  circular  of  instruction  many  patients  of  "  fresh 
and  previous  dispositions"  begin  to  use  the  hand  injections  too  early 
and  then  blame  the  physician  for  the  results  which  they  themselves 
invite  by  such  self-treatment. 


TREATMENT  IN  GENERAL  63 

The  special  syringe  insisted  on  i)y  tiie  author  is  flepicted  in  I^'ig.  01 . 
Its  size  is  so  small  (2  drams)  that  too  much  fluid  cannot  be  injected 
into  the  average  urethra.  Its  all-glass  construction  renders  it  steriliz- 
able  by  boiling  and  its  wooden  container  is  a  prophylactic  against 
contaminating  pockets  and  their  contents  or  other  utensils  on  shelves 
besides  the  syringe. 

The  limit  of  injections  is  to  the  anterior  urethra  alone  so  far  as  j^ossi- 
ble.  Hence  the  patient  should  understand  that  his  disease  is  located 
in  the  anterior  urethra  which  alone  should  be  injected  with  the  medi- 
cine and  that  this  result  is  obtainable  by  the  use  of  small  quantities 
and  great  gentleness,  leaving  Nature  to  carry  the  fluid  along  the 
mucosa  as  she  will  by  capillary  attraction  between  the  walls  which  are 
in  apposition.  He  should  also  comprehend  that  forcible  injection 
traumatizes  and  irritates  the  mucosa  and  extends  the  infection.  His 
"frenzy  for  quick  cure"  should  be  quieted  in  every  possible  way. 

The  frequency  of  injections  in  the  author's  practice  is  at  first  twice  a 
day  for  one  or  two  days,  then  three  times,  and  by  slow  increase  finally 
six  times  a  day — in  other  words,  about  every  two  or  three  hours  of 
the  waking  period  or,  what  is  usually  the  same  thing,  after  each  urina- 
tion unless  there  are  contraindications.  Office  catheter-and-syringe 
irrigations  are  given  properly  balanced  between  these  jiand  injections. 
Each  irrigation  is  regarded  as  supplanting  one  hand  injection.  If 
therefore  the  patient  is  taking  four  injections  at  home  and  one  office 
irrigation  these  measures  are  regarded  as  the  equivalent  of  five  similar 
treatments  in  a  day.  If  more  than  one  office  irrigation  is  desirable, 
for  example,  one  each  night  and  morning,  then  the  patient  omits  the 
hand  injection  for  the  corresponding  time.  This  is  important  espe- 
cially when  the  activity  of  treatment  is  decreased,  otherwise  over- 
treatment  w^ith  all  its  disadvantages  will  result. 

The  retention  of  injections  for  five  to  ten  minutes  augments  the  ger- 
micidal function  of  the  injection  by  bringing  the  antiseptic  into  pro- 
longed contact  with  the  organisms  as  they  lie  upon  the  epithelia  and 
by  permitting  it  to  soak  into  and  between  the  epithelia,  where  they 
lurk,  and  also  fulfils  the  indication  of  persistent  gentle  action  exactly 
like  that  of  the  protective  faculties  of  the  blood,  which  are  chemically 
not  strong  but  act  persistently.  The  urethra  may  be  closed  by  the 
fingers  of  the  patient  or  by  use  of  one  or  other  of  the  various  urethral 
clamps,  of  which  one  of  the  best  is  that  of  Chetwood.^ 

On  these  points  Taylor^  has  the  following  apt  dictum :  "  It  is  a  good 
rule  to  begin  with  the  slow  injection  of  about  1  dram  of  fluid,  and 
then  to  increase  as  the  tolerance  of  the  urethra  will  admit,  until  a 
syringeful  can  be  throwii  into  the  canal  without  any  resistance  what- 
ever. In  this  way  the  urethra  becomes  accustomed  to  the  operation, 
and  its  walls  can  be  well  acted  upon  by  the  medicated  fluid." 

In  the  technic  the  first  step  is  to  evacuate  the  bladder,  cleansing  the 
urethra.     The  patient  rolls  his  shirt  to  his  armpits  and  his  trousers 

1  Practice  of  Urology,  1913,  p.  17.  ^  Loc.  cit.,  p.  62. 


64 


ACUTE  URETHRITIS 


and  tlrawt'i-s  tt>  liis  kuoes  and  protects  the  latter  with  pajx^r  or  linen 
towels  from  leakage,  as  many  of  the  Naluable  drugs  stain.  Towels 
should  also  cover  the  utensils  used.  He  stands  over  a  basin  or  the 
urinal  of  a  water-closet,  \\'ith  his  legs  conveniently  separated,  or  sits 
on  the  cilge  of  a  chair  with  a  receptacle  on  the  floor  or  sits  far  back 
on  a  toilet  seat — all  so  that  leakage  may  be  received.  The  penis  is 
grasped  between  the  fourth  and  fifth  fingers  and  the  palm,  leaving 
the  thmnb,  index  and  middle  finger  to  manage  the  glans  and  meatus. 
A  smoothly  working  cone-point  syringe  is  jiressed  into  the  meatus 
watertight,  aided  by  the  tlnmib  and  forefinger,  which  first  open  the 
canal  and  then  close  it  against  the  tip  of  the  syringe.  The  direction  of 
the  instrunuMit  for  outflow  and  the  pressure  against  leakage  must  be 


■ 

m 

■* 

\k 

E 

^L^ 

1    ■ 

1 

t' 

**^ 

»**^... 

Fig.  1-4. — Irrigation  for  the  anterior  uretliral  glass  in  the  aulliur's  seven-glass  test 
(original).  After  standard  drapery  (Fig.  15)  a  large  sterile  glass  is  held  by  the  strap  at 
the  upper  end  of  the  Wolbarst  basin.  The  left  hand  supports  the  catheter  within  the 
penis  and  makes  it  coil  -within  the  glass.  The  right  hand  makes  the  irrigation  with  a 
Janet-Frank  syringe  and  the  outflow  is  conducted  by  the  course  of  the  catheter  directly 
into  the  glass  as  shown.  The  author's  seven-glass  test  is  fully  described  on  page  455, 
in  Chapter  VIII,  on  General  Principles  of  Diagnosis. 


acquired  only  with  practice,  as  few  patients  ha^•e  the  knack  without 
it.  Gentle  slow  pressure  to  fill  the  urethra  exactly  as  it  is  dm-ing  urina- 
tion without  pain  or  discomfort  is  the  next  step  followed  by  the  final 
detail  of  retaining  the  fluid  for  five  or  ten  minutes  actual  time  "by  the 
watch"  by  closing  the  canal  with  the  finger  or  a  clamp. 

Catheter  irrigations  constitute  the  office  treatment  as  soon  as  the 
hand  injections  have  been  ordered  and  therefore  begin  with  the 
declining  period  of  symptoms  and  organisms.  The  in.struments  are  a 
150  c.c.  Janet-Frank  or  equivalent  syringe  and  a  reflux,  size  12,  French, 
soft-rubber  catheter,  illustrated  in  Fig.  14,  or  a  short  velvet-eye  soft- 
rubber  catheter,  size  10,  French,  a  suitable  graduate  for  mixing  the 
injection  and  the  necessary  towels  and  other  dressings.  The  limit  of 
the  inigation  is  to  the  anterior  urethra  exactly  as  that  of  the  hand 


TREATMENT  IN  GENERAL 


65 


injection,  because  the  disease  is  at  least,  so  far  as  the  infection  is 
concerned,  confined  to  the  anterior  urethra,  althouj^li  the  posterior 
portion  may  have  a  sympathetic  congestion  without  symptoms. 

In  good  technic  the  patient  always  urinates  in  the  presence  of  the 
urologist,  cleansing  the  urethra  as  a  preliminary,  and  then  standing 
with  his  clothing  adjusted  exactly  as  for  the  hand  injection,  and 
preferably  reclining  on  a  couch  or  operating  table,  with  the  Woll^arst 
basin  or  other  receptacle  between  his  separated  thighs,  is  ready.  The 
urologist  passes  the  catheter  for  only  three  or  four  inches,  or  until  he 
feels  the  slight  resistance  of  the  bulb  of  the  urethra,  and  then  attaches 
the  previously  filled  syringe.  Two  or  three  small  pieces  of  gauze  are 
laid  over  the  glans  and  catheter  loosely,  so  that  the  penis  may  be  held 
and  the  catheter  retained  with  the  fingers  without  infection  of  the 


Fig.  15. — Standard  drapery  in  the  reclining  position  (original).  The  patient  is  on  an 
operating  table,  with  leggings  (Fig.  193)  up  to  the  groins  and  the  Wolbarst  basin  between 
his  thighs.  The  author's  perforated  towel  (Fig.  196)  is  passed  over  the  penis  so  that  its 
short  end  covers  the  upper  portion  of  the  basin  for  antisepsis,  and  its  long  end  covers 
the  abdomen. 


hand,  and  next  with  great  gentleness  and  with  no  further  distention 
than  the  urine  itself  makes,  the  urologist  slowly  irrigates  the  canal 
for  about  five  minutes — thus  fulfilling  the  indications  of  mechanical 
cleansing,  gentleness  without  irritation  and  prolonged  influence  of 
the  antiseptic  or  astringent.  The  fluid  should  be  warm  or  comfortably 
hot. 

The  standard  drapery  of  the  patient  differs  in  the  reclining  and  the 
standing  positions  for  the  various  methods  of  treatment.  In  the 
reclining  posture  the  patient  is  on  his  back  on  a  suitable  urological 
table,  with  his  shirt  rolled  up  to  his  arm-pits  in  front  and  behind  and 
his  trousers  and  drawers  rolled  down  to  his  knees,  or  if  prolonged  irri- 
gation is  to  be  done  they  had  best  be  removed  and  the  leggings  sho-mi 
in  Fig.  193  (page  721)  put  on  in  their  stead.  The  warmed  Wolbarst 
basin  is  placed  between  the  thighs,  and  then  the  perforated  towel 
detailed  in  Fig.  727  is  passed  over  the  penis,  with  the  long  portion 
5  ■ 


C^C^  ACUTE  URETHRITIS 

upon  the  chest  and  the  short  i)avt  Ix'tAveen  the  penis  and  tlie  basin 
for  cleanliness  and  elegance.  Any  treatment  ^vhate^'er  may  now 
be  developed  without  soiling  the  patient's  clothing,  because  the  basin 
and  draperies  receive  all  splash.  If  instrumental  treatment  is  to  be 
performed  the  basin  is  not  used  except  Avith  the  author's  irrigating 
sounds,  when  it  is  i)laced  in  position  during  the  ])eriod  of  washing  just 
at  the  knees  to  correspond  with  the  outlet  of  the  sound.  If  the 
Wolbarst  basin  is  not  at  hand  a  douche-pan  may  rest  beneath  the 
patient's  hips  and  well  down  toward  the  knees,  or  the  return  flow  may 
be  received  into  the  dou^'he-i)an  of  the  urological  table,  as  usually 
provided.  In  the  standard  posture  the  clothing  is  arranged  in  exactly 
the  same  way  and  the  perforated  towel  is  used  with  the  long  part  over 
the  thighs  and  the  short  i)ortion  held  by  the  patient  over  the  abdomen. 
Another  towel  is  spread  over  the  edge  of  the  basin  or  sink  in  the 
office,  against  which  the  patient  leans  or  the  hand  basin  may  be  held 
as  shown  in  Fig.  I'.].  These  basins  are  readily  sterilized,  so  that  an 
experienced  patient  and  a  skilful  operator  make  the  towels  unneces- 
sary. 

Fluids  for  hand  injections  and  irrigations  should  always  be  selected 
with  reference  to  heat  and  the  a\'oidance  of  overaction.  The  object 
of  freeing  the  surface  of  clinging  pus,  of  mild  penetration  of  the  medi- 
cine, with  hj^eremia  rather  than  irritation,  must  be  borne  in  mind, 
and  when  in  doubt  weaker  solutions  and  less  active  agents  must  first 
be  tried  and  strength  and  action  augmented  by  graduated  steps.  The 
following  list  is  suggestive : 

ArgjTol 3  to  10  per  cent. 

Protargol §  to    1  per  cent. 

These  newer  silver  salts  have  stood  the  test  of  >'ears  with  decided 
satisfaction.  The  former  is  rather  the  more  commonly  used  because 
much  the  less  irritating.  For  reasons  unknown  both  these  salts  are  of 
value  in  the  body  in  controlling  the  infection  and  its  results,  although 
in  the  laboratory  their  germicidal  power  is  ver^^  little.  They  probably 
act  in  three  ways:  (1)  By  penetrating  the  diseased  epithelia  they 
hasten  its  exfoliation,  (2)  by  entering  betw^een  the  epithelia  they 
destroy  the  gonococci  and  (3)  by  causing  hyperemia  aid  both  these 
processes  on  Nature's  part. 

When  these  silver  salts  are  not  tolerated  or  not  available  or 
when  additional  measures  are  indicated,  the  following  solutions  are 
advised : 

Normal  salt  solution 0.6  per  cent. 

Boric  acid  water 2  to  4  per  cent. 

Liquor  plumbi  subacetatis half  to  full  strength  (U.  S.  P.) 

Potassium  permanganate  solution 1  in    8000  to  1  in  4000 

Sulphate  of  zinc  solution 1  in      500  to  1  in    250 

Alum  solution 1  in      500  to  1  in    250 

Sulphate  of  copper  solution 1  in  10000  to  1  in  2000 

Chloride  of  zinc  solution 1  in  10000  to  1  in  2000 

Nitrate  of  silver  solution 1  in  10000  to  1  in  1000 


TREATMENT  IN  GENERAL  67 

In  general  the  concentration  is  from  0.5  to  1  per  cent,  for  all  the 
weaker  salts  and  a  tenth  part  or  a  twentietli  part  of  these  stn-n^tlis 
for  the  three  stronger  solutions  headed  by  nitrate  of  silver,  at  the  bot- 
tom of  the  list  and  including  potassium  i)ermangana,t(;.  'J'he  normal 
salt,  boric  acid  and  weak  lead-water  are  mechanical  cleansing  agents, 
while  the  potassium  permanganate  is  one  of  the  best  antiseptics  and 
astringents,  followed  by  the  other  salts,  which  are  valuable  chiefly 
for  their  astringency  and  stimulus  of  the  mucosa  in  the  strengths 
commonly  used.  Thus  the  list  presents  the  order  of  choice  from  the 
onset  of  local  treatment  in  the  early  decline  to  its  cessation  in  the  ter- 
minal weeks. 

Formulas  for  hand  injections  and  irrigations  are  chiefly  combinations 
of  the  foregoing  solutions  and  should  be  applied  according  to  the  rules 
already  detailed.  The  following  examples  are  very  valuable,  similarly 
prepared  and  marked : 

I^ — Zinc  acetate 0.75  grammes  (grains  12) 

Liquor  of  lead  subacetate 4.0    grammes  (dram -1) 

Distilled  water  up  to 180.0    grammes  (ounces  6) 

I^— Sulphate  of  zinc 0.375-0.475    gramme  (grains  6  to  8) 

Magendie's  solution  of  morphin       .      .      .  8.0    grammes  (drams  2) 

Distilled  water  up  to 120  grammes  (ounces  4) 

I^ — Zinc  sulphate 

Lead  acetate of  each  0.375  to  0.75  grammes  (grains  6  to  12) 

Distilled  water     .......       up  to  180  grammes  (ounces  6) 

I^ — Potassium  permanganate 0.03125  gramme    (grain  J) 

Distilled  water 180  grammes  (ounces  G) 

Mix,  make  a  solution  and  mark: 

External  use  as  a  hand  injection  from  three  to  six  times  daily  as  directed. 

Internal  Measures. — During  the  period  of  decline  with  its  local  treat- 
ment neutralization  of  the  urine  is  a  much  less  important  indication 
than  soothing  the  mucosa  and  stimulating  it  to  a  more  normal  secre- 
tion. The  varieties  of  drug  are  the  blennorrhetic  oils  and  oleoresins, 
the  anodynes  and  sedatives  and  finally  the  urinary  antiseptics — 
separately  but  more  commonly  combined  in  prescriptions. 

The  oils  preferred  are  sandalwood,  cubeb,  turpentine,  wintergreen 
and  olive  oil,  which  are  administered  in  soft,  soluble  capsules,  contain- 
ing from  5  to  10  minims  each,  three  times  daily,  so  that  the  patient  by 
slow  increase  receives  from  15  to  60  minims  in  the  twenty-four  hours. 
The  chief  cautions  are  not  to  disturb  the  digestion,  evidenced  by 
eructations,  or  the  kidneys,  suggested  by  dull,  dragging  distress  in  the 
renal  zone.  Some  patients  break  out  in  violent  rashes  after  these 
medicines.  The  oil  of  wintergreen  is  of  service  when  rheumatic  signs 
begin  to  appear. 

The  oleoresins  are  copaiba,  cubeb  and  matico,  but  for  many  diges- 
tions are  less  readily  assimilable.  Formulas  combining  the  oils  with 
each  other  and  with  the  oleoresins  follow.  For  patients  who  cannot 
afford  these  refined  medicines,  and  when  they  are  not  readily  and 


68  ACUTE  URETHRITIS 

consistently  obtainaMc,  tlie  so-oallod  co])ailia  ccMiijioiuul   {" Lafaycffe 
mixture')  is  advisetl: 

I^ — Copaiba 0.5    gramme  (minims  8) 

Spirit  of  nitrous  ether 0.5    gramme  (minims  8) 

Compound  tincture  of  lavender O.S    gramme  (minims  10) 

Liquor  of  potassium  hydroxide 0. 13  gramme  (minims  20) 

Tragacanth sufficient 

Distilled  water  up  to 4.0    gramme  (dram  1) 

Mix,  make  a  solution  and  mark: 

One  teaspoonful  three  times  a  day,  with  a  glass  of  water,  two  hours  after  eating. 

^ — Copailia 0.25      gramme  (minims  4) 

Oil  cubeb     . 0.125    gramme  (minims  2) 

Oil  turpentine 0.25      gramme  (minims  4) 

I^ — Copaiba 0.4375  gramme  (minims  7) 

Oil  cubeb 0.1875  gramme  (minims  3) 

I^ — Copaiba 0.4375  gramme  (minims  7) 

Oil  santal 0. 1875  gramme  (minims  3) 

I^ — Copaiba 0.4375  gramme  (minims  7) 

Oleoresin  cubeb 0 .  125    gramme  (minims  2) 

Extract  of  buchu 0.125    gramme  (grains  2) 

I) — Copaiba 0 .  375    gramme  (minims  6) 

Tincture  ferric  chloride  (equivalent)              .      .      0.125    gramme  (minims  2) 
Oleoresin  cubeb       .    ^ 0.125    gramme  (minims  2) 

I^ — Copaiba 0.1875  gramme  (minims  3) 

Oleoresin  cubeb 0.1875  gramme  (minims  3) 

Oleoresin  matico 0.0625  gramme  (minims  1) 

Oil  santal 0. 1875  gramme  (minims  3) 

I^ — Copaiba 0.375    gramme  (minims  6) 

Oil  cubeb 0.125    gramme  (minims  2) 

Oil  santal 0.125    gramme  (minims  2) 

The  urinary  antiseptics  are  usually  given  alone  in  tablet  or  powder 
form,  but  preferably  in  solution  and  choice  seems  to  remain  with 
hexamethylenamin,  grains  5  to  7h,  salol,  grains  5  to  10,  sodium  ben- 
zoate,  grains  5  to  10,  sodiimi  salicylate,  grains  5  to  10,  and  sodium 
biborate,  grams  5  to  15,  acid  phosphate  of  soda,  grains  5  to  20 
— dissolved  in  1  or  2  drams  of  water,  and  taken  three  times 
a  day,  two  hours  after  eating.  The  benzoate  of  soda  is  advan- 
tageously combined  with  the  formaldehyde  preparations,  of  which 
hexamethylenamin  is  the  most  reliable,  and  both  drugs  are  em- 
ployed in  equal  quantities  to  the  teaspoonful  dose,  grains  5,  7^  or 
10.  Good  combinations  of  the  blennorrhetics  and  urinary  antiseptics 
are  the  following  two  formulas  for  soft  soluble  capsules,  of  which  one 
is  to  be  taken  three  times  a  day,  two  hours  after  eating: 

I^— Salol .       .      .0.228    gramme  (grains  3.5) 

Copaiba 0.625    gramme  (minims  10) 

Oleoresin  of  cubeb 0.3125  gramme  (minims  5) 

Pepsin 0.0625  gramme  (grain  1) 

I^ — Salol  .      .      .• 0.25      gramme  (grains  4) 

Oleoresin  of  cubeb 0.3125  gramme  (minims  5) 

Pepsin 0.0625  gramme  (grain  1) 

Oil  of  sandalwood 0.3125  gramme  (minims  5) 

Olive  oil 0.3125  gramme  (minims  5) 


TREATMENT  IN  GENERAL  69 

The  sedatives  and  anodynes  are  invariably  given  alone  for  incidentally 
severe  symptoms  which  last  at  the  most  a  few  days,  as  a  rule,  or  even 
less,  and  therefore  coutraindicate  continued  administration  in  these 
compounds.  A  sufficient  number  have  already  })cen  named  mulcr  the; 
subjec  tof  Chordee. 

The  disadvantages  of  the  internal  medication  are  that  all  the  oils, 
oleoresins  and  urinary  antiseptics  have  a  more  or  less  disturbing 
influence  on  digestion,  especially  if  taken  too  soon  after  eating.  The 
proper  interval  is  about  two  hours  after  the  meal,  when  the  stomach  is 
about  to  empty  itself.  Many  also  irritate  the  kidneys,  especially  the 
antiseptics,  which  may  cause  renal  hematuria,  and  the  oils,  character- 
ized by  lumbar  discomfort,  if  not  pain.  And  finally  the  oils  and  oleo- 
resins cause  rashes  of  the  skin,  of  almost  alarming  severity,  resembling 
scarlet  fever.  All  these  incidents  indicate  temporary  cessation  and 
thereafter  alternation  to  avoid  a  return  of  these  symptoms. 

Stage  of  Termination. — In  the  last  period  of  the  disease  the  subjec- 
tive symptoms  are  little  or  absent  and  the  objective  signs  show  the  dis- 
charge thin  and  scanty  or  absent,  except  for  shreds  in  the  urine,  so  that 
glass  1  is  clear,  with  shreds  or  slightly  turbid  with  mucus,  which  contains 
shreds,  and  glass  2  is  clear,  with  no  shreds  or  a  very  few.  The  lesion 
is  therefore  catarrhal  rather  than  suppurative,  although  pus  under 
the  microscope  may  still  occur.  The  incidence  of  the  catarrh  is  diffi- 
cult to  explam  to  many  patients  who  cannot  comprehend  that  catarrh 
is  both  the  preliminary  manifestation  before  the  pus  appears  and  the 
terminal  manifestation  after  the  pus  disappears.  Often  patients  will 
seek  the  services  of  another  practitioner  because  they  regard  the  terminal 
catarrh  as  a  new  disease,  which  incompetence  has  rendered  possible. 

Local  measures  are  the  hand  injections,  irrigations  and  instillations, 
employing  by  preference  only  astringent  and  stimulating  rather  than 
purely  antiseptic  combinations. 

The  hand  injections  are  the  same  as  those  recommended  for  the  earlier 
declining  period,  but  w^eaker  strengths,  so  that  quarter-strength  or  half- 
strength  solutions  are  employed  of  the  newer  silver  salts,  when  germi- 
cidal influence  is  still  called  for,  and  of  the  zinc  and  alum  formulas  as 
corrigents  of  the  silver  nitrate  combinations.  This  last  drug  is  the 
best  of  all  in  this  period. 

The  irrigations,  with  the  same  equipment  as  described  on  page  64, 
are  begun  with  silver  nitrate  solutions,  1  in  10,000,  gradually  increased 
to  1  in  1000,  employing  from  100  to  150  c.c.  at  one  treatment,  with  the 
reflux  catheter  to  confine  the  application  to  the  anterior  urethra.  Irri- 
tation from  the  nitrate  of  silver  indicates  dividing  the  given  strength 
into  halves  and  also  decreasing  the  frequency,  which,  according  to  the 
response,  is  every  other  day,  until  fluid  pus  disappears.  Then  both 
the  hand  injections  and  the  irrigations  are  discontinued.  The  slight- 
est tendency  tow^ard  persistence  of  shreds  after  a  short  period  of  rest 
foretells  chronicity  and  requires  the  next  step  in  treatment. 

Instillations. — The  small,  4-dram  instillation  syringe  of  Hayden  (Fig. 
7-F) ,  with  the  short,  velvet-eye  soft-rubber  catheter,  size  10  or  12,  French, 


70  ACUTE  URETHRITIS 

cannot  be  inii)rove(l  as  instruments,  because  the  syringe  is  so  small  that 
undue  (juantity  of  tkiid  cannot  be  enii)loyed  and  the  catheter  is  both 
too  short  and  too  tiiin  to  extend  the  fluid  beyond  the  anterior  urethra 
or  preAent  it  from  escaping  at  tiie  meatus.  The  strengths  of  silver 
nitrate  solution  employed  gradually  increase  from  the  lowest  to  the 
highest,  with  recessions  to  weaker  solutions  should  any  be  found  to 
cause  irritation. 

The  percentages  reconnnended  are  as  follow: 


1  to  5000 

1  to  2000 

1  to  750 

1  to  125 

1  to  4000 

1  to  1500 

1  to  500 

2  to  100 

1  to  3000 

1  to  1000 

1  to  250 

5  to  100 

The  frequency  is  every  other  day,  with,  as  anile,  one  ascent  in  strength 
at  each  visit  until  about  1  in  1000  is  reached,  because  the  higher  con- 
centrations are  liable  to  irritate  so  that  the  increase  must  be  much  more 
slow.  The  quantity  is  1  to  2  drams  except  the  2  in  100  and  5  in  100,  of 
which  only  a  few  drops  may  be  emi)loyed  at  points  of  soreness  com- 
plained of  by  the  patient.  Force  is  reduced  to  great  gentleness,  so  that 
the  fluid  runs  in  and  out  along  the  catheter,  and  retention,  while  the 
patient  counts  thirty  slowly,  of  the  last  dram  or  half-dram,  is  a  good 
rule  and  accomplished  by  ha\'ing  him  squeeze  the  meatus  shut  while 
the  catheter  is  slowly  withdrawn.  With  scientific  observation  of  the 
progress  of  the  disease  by  stages,  accompanied  by  judicious  progress 
in  the  treatment,  very  frequently  no  true  chronic  stage  with  prolonged 
and  \'arial)le  s^'mptoms  and  perhaps  with  absorption  ensues. 

Internal  measures  duplicate  those  for  the  ])revious  period,  with  the 
tendency  to  decrease  quantities  and  frequencies  and  to  substitute 
tonic  measures.  Full  diet  without  high  seasoning  and  alcohol  and 
moderate  exercise  are  permissible.  Sexual  excitement,  direct  and 
indirect  and  with  or  without  intercourse,  is  forbidden  through  the 
trel)le  risk  of  relapse  or  reinfection  of  the  patient  or  transmission  of 
the  disease  to  the  woman. 

Aftertreatment. — ^Yhen  all  symptoms  have  disappeared  and  active 
measures  have  been  abandoned,  a  short  period  of  aftercare  is  necessary 
for  the  severe  cases.  This  involves  a  few  weekly  visits  in  order  to  be 
sure  that  signs  of  disease  do  not  appear  without  attracting  the  atten- 
tion of  the  patient  and  in  order  to  build  up  the  patient  should  his 
illness  have  dejireciated  his  physical  and  nervous  state. 

All  normal  habits  of  life  are  slowly  resumed.  After  treatment  is 
stopped  a  month  or  two  of  observation  and  frequent  tests  must  all 
show  absence  of  the  gonococcus  and  then  cure  is  pronounced. 

Irrigation  Method. — Definition. — A  local  antiseptic  attack  against 
the  infection  is  the  predominant  feature  of  the  irrigation  treatment 
irrespective  of  the  \'arious  stages  of  the  disease  and,  to  less  extent,  of 
the  various  internal  and  other  local  measures,  such  as  hand  injections. 
For  this  reason,  whether  the  patient  is  seen  first  in  the  invasion,  early 
or  late  estal)lishment  or  declining  period,  the  washings  of  the  urethra 
are  begun,  but  are  always  graduated  carefully  in  accordance  with  the 
response. 


TREATMENT  IN  GENERAL  71 

Purposes. — All  comprise  prevention  of  possible  infection  within  a 
few  hours  of  suspicious  coitus,  as  discussed  in  the  general  topic  of 
Prophylaxis  (page  483),  and  of  inoculation  with  instruments  of  any 
part  of  the  urethra  de  novo  or  by  passage  through  an  infected  to  a 
healthy  portion,  and  likewise  include  actual  cure  of  infection  recently 
or  remotely  established. 

Internal  Measures. — Internal  measures  are  the  same  as  those 
employed  in  the  conservative  method  and  are  varied  according  to  the 
stages,  so  that  early  dilution  and  neutralization  of  the  urine  are  sought 
and  later  soothing  and  stimulation  of  the  urethral  mucosa.  No  further 
discussion  of  the  means  and  formulae  employed  is  necessary  beyond 
that  just  given  in  the  previous  paragraph. 

Local  Measures. — Local  measures  are  comprised  in  urethral  irriga- 
tions of  three  kinds:  (1)  syringe  and  catheter  method,  already  fully 
described,  which  is  rarely  extended  to  the  activity  implied  in  the  irri- 
gation treatment,  but  is  commonly  restricted  to  correlation  with  hand 
injections;  (2)  the  Janet  method  devised  by  Janet^  in  1892,  but  modified 
by  Valentine  and  Swinburne  chiefly  in  the  details  of  nozzles,  cutoffs  and 
reservoirs;  (3)  the  Chetwood  double  current  method. 

Janet-Valentine^  method  requires  as  its  equipment  a  wall  bracket 
with  pulleys,  over  which  runs  a  chain  or  cord  suspending  a  glass 
reservoir,  with  conical  bottom,  attaching  a  long  rubber  hose  leading 
to  a  special  cut-off  and  shield,  and  which  receives  one  of  four  varieties  of 
glass  tip,  respectively  for  the  normal,  large  or  small  male  and  the 
female  urethra.  The  patient's  preparation  involves  adjustment  of  the 
clothing,  with  the  shirts  rolled  to  the  breasts  and  the  trousers  dropped 
to  the  knees.  He  may  assume  sitting,  reclining  or  standing  posture, 
having  the  following  details:  The  sitting  posture  is  with  the  sacrum 
at  the  edge  and  the  shoulders  upon  the  back  of  a  strong  chair  and  the 
feet  on  the  floor.  The  reclining  position  involves  the  ordinary  operating 
table  and  the  standing  attitude  is  in  front  of  a  sink  or  other  fixture. 
Towels  or  an  apron  protect  the  clothing  from  splash  and  a  scalded 
and  cleansed  receptacle,  by  preference  the  Wolbarst  basin,  is  placed 
between  the  thighs,  with  the  penis  over  its  edge,  so  that  the  return 
flow  is  readily  received  into  it.  A  bed-pan  or  Kelly  pad  may  be  used 
instead  under  the  patient  on  an  operating  table,  but  usually  soils  the 
buttocks  so  that  the  basin  is  much  preferred. 

The  technic  begins  and  ends  with  sterilized  utensils  and  instruments 
and  requires  the  urologist  at  the  side  of  the  patient.  All  surfaces  of  the 
penis,  foreskin  and  glans  are  cleansed  wdth  antiseptic  wash  and  cotton 
swabs  or  with  the  irrigating  fluid  played  first  over  the  organ,  and  then 
in  order  over  the  foreskin  and  glans,  with  its  folds  and  sulci,  and  finafly 
the  meatus  held  open  by  digital  pressure.  The  stream  is  next  turned 
into  the  urethra  by  holding  the  nozzle  against  the  meatus  tightly 
enough  to  permit  inflow,  but  not  to  exclude  outflow,  which  is  imme- 
diately favored  by  slight  withdrawal  as  soon  as  the  urethra  seems 

1  Ann.  de  dermat.  et  de  syph.,  1893,  iv,  1016. 

2  Irrigation  Treatment  of  Gonorrhea,  its  Local  Complications  and  Sequelse,  1913. 


72  ACUTE  URETHRITIS 

distended.  Force  is  ileterniined  by  the  lieight  of  the  irrigator  above 
the  patient's  head,  and  should  be  sufficient  to  fill  but  not  stronfjly 
dihite  the  canal,  and  always  without  ])ain,  bleedinji;  or  other  irritation. 
The  author  believes  that  the  niaruin  of  safety  re([uires  a  ])ressure  only 
equal  to  that  of  the  m*ine,  and  therefore  does  not  elevate  the  reservoir 
above  the  patient's  ear.  Duration  of  from  fi^•e  to  ten  minutes  is  usually 
sufficient,  although  the  longer  the  irrigation  the  better  if  gentleness 
and  relative  dilution  of  the  fluid  are  observed.  Teni])erature  is  within 
tolerance  and  ranges  from  105°  to  120°  Y.  Avithout  secondary  irritation. 
The  greater  the  heat  well  borne  the  higher  the  astringency  and  anti- 
septic value,  as  a  rule.  Limitation  of  the  irrigation  to  the  anterior 
urethra  is  recommended  b>'  \'alentine^  in  the  special  method  of  holding 
the  shaft  of  the  penis  and  urethra  in  the  third,  fourth  and  fifth  fingers, 
which  are  released,  one  at  a  time,  as  the  fluid  reaches  it,  until  finally 
it  passes  to  the  bulb.  Frequency  is  outlined  by  the  following  table  of 
Valentine,  modified  from  Janet,  containing  allusion  to  intravesical 
irrigations  discussed  under  this  form  of  treatment  of  posterior  urethritis. 

First  day,  first  ^^sit         Anterior  irrigation 1  to  3000 

First  day,  7  p.m.  Anterior  irrigation 1  to  4000 

Second  day,  9  a.m.  Anterior  irrigation 1  to  3000 

Second  day,  7  p.m.  Anterior  irrigation 1  to  4000 

Third  day,  9  a.m.  Intravesical  irrigation 1  to  6000 

Third  day,  7  p.m.  Anterior  irrigation 1  to  5000 

Fourth  day,  9  a.m.  Intravesical  irrigation 1  to  5000 

■r, .,    J        -  /  Intravesical  irrigation 1  to  5000 

ifourtn  day,  7  p.m.        {   a    ,     •      •    ■     .■  i  >.    oa^a 

(  Anterior  irrigation 1  to  2000 

Fifth  day,  noon  Intravesical  irrigation 1  to  5000 

Si.xth  day,  noon  Intravesical  irrigation 1  to  5000 

Seventh  daj',  noon  Intravesical  irrigation 1  to  5000 

Intravesical  irrigation 1  to  5000 

Anterior  irrigation 1  to  3000 

Intravesical  irrigation 1  to  5000 

Anterior  irrigation 1  to  2000 

Intravesical  irrigation 1  to  4000 

Anterior  irrigation 1  to  1000 

xt:^+v  ^„,,   T  ,, ,,  /  Intravesical  irrigation 1  to  4000 

JNinth  day,  7  p.m.          <   a    ^     ■      •    •     x-  ■,  ^    iaaa 

'  Anterior  irrigation 1  to  1000 

Intravesical  irrigation 1  to  5000 

Anterior  irrigation 1  to  5000 


Eighth  day,  9  a.m. 
Eighth  day,  7  p.m. 
Ninth  day,  9  a.m. 


Tenth  day,  9  a.m. 


The  Chetwood^  double  current  method  also  demands  sterilized  instru- 
ments and  utensils,  before  and  after,  but  has  a  somewhat  different 
equipment  in  the  bracket,  pulleys,  chain  and  jar,  but  chiefly  in  the 
double  current,  scissors  handle,  cut-oft'  and  Y-shaped  glass  nozzles 
adapted  for  the  various  sizes  of  meatus  and  urethra.  The  patient's 
preparation  is  exactly  the  same  as  just  detailed,  in  the  standing,  sitting 
or  reclining  postm-e.  Force  is  again  limited  to  that  of  the  normal 
urinary  stream,  in  the  author's  opinion,  and  in  his  practice  is  detected 
by  holding  the  penis  against  the  palm  of  the  hand,  with  the  finger-tips 
over  the  urethra  in  order  to  feel  the  resistance.  Discomfort  or  pain 
immediately  requires  lowering  the  irrigator  even  below  the  ear  of  the 
patient. 

>  Loc.  cit.,  p.  18.  2  Practice  of  Urology,  1913. 


TREATMENT  IN  GENERAL  73 

The  technic  consists  in  holding  the  correct  size  of  nozzk;  water  tight 
against  the  meatus,  gently  filling  the  canal  to  the  bulb,  and  then  by 
closing  the  scissors  handle  cut-oft'  allowing  the  charge  of  fhiid  to  escape 
into  a  receptacle.  This  process  is  alternately  continued  until  the  canal 
is  suitably  cleansed.  All  the  other  features  are  the  same  as  in  the 
Janet- Valentine  method,  especially  preliminary  washing  of  the  organ, 
duration,  temperature,  limitation  and  frequency  of  the  irrigation. 

Solutions  for  irrigations  do  not  depart  in  constituents  or  strengths 
from  the  formulas  for  hand  injections,  but  may  have  fewer  elements 
and  much  greater  quantities.  Stock  solutions  ready  for  dilution  in 
varying  strengths  up  to  full  concentration  are  convenient  as  follows: 

IJ — Crude  alum 1  part 

Zinc  sulphate 1  part 

Distilled  water  up  to 500  parts 

Mix,  make  a  solution  and  dilute  according  to  table. 

IJ — Permanganate  of  potash 1  part 

Distilled  water  up  to 500  parts 

Mix,  make  a  solution  and  dilute  according  to  table. 

I^ — Nitrate  of  silver 1  part 

Distilled  water  up  to 500  parts 

Mix,  make  a  solution  and  dilute  according  to  table. 

The  first  formula  is  chiefly  astringent  and  the  least  active;  the  potas- 
sium permanganate  adds  antisepsis,  with  little  astringency,  while  the 
silver  nitrate  possesses  both  actions  in  marked  degree  so  that  increases 
in  strength  should  be  slowest  with  it,  but  may  be  more  rapid  with  the 
other  two  solutions,  always  according  to  reaction. 

TABLE  OF  DILUTION  OF  STOCK  SOLUTIONS. 

Quantity  of 
1  to  500 
stock.  Quantity  of  water.  Total  irrigation.  Strength  of  irrigation. 

3  c.c.  97  c.c.  100  c.c.  1  in  15,000  + 

5  c.c.  95  c.c.  100  c.c.  1  in  10,000 

10  c.c.  90  c.c.  100  c.c.  1  in  5,000 

20  c.c.  80  c.c.  100  c.c.  1  in  2,500 

30  c.c.  70  c.c.  100  c.c.  1  in  1,500 

50  c.c.  50  c.c.  100  c.c.  1  in  1,000 

100  c.c.  0  c.c.  100  c.c.  1  in   500 

In  the  terminal  stage  of  acute  disease  solutions  stronger  than  1  in 
2500  or  1  in  1500  are  rarely  necessary.  Resistance  to  these  strengths 
foretells  chronic  conditions. 

Cure. — Cure  cannot  be  pronounced  until  the  m'ine  is  clear  of  mucus, 
pus  or  shreds,  and  has  remained  so  for  a  long  time,  and  so  continues  in 
the  presence  of  irritation  by  intentional  errors  of  diet,  the  beer  test  and 
mildly  irritating  instillations.  A  few  mucous  shreds,  with  minimal 
pus,  are  allowed  provided  in  any  and  all  circmustances  the  gonococcus 
is  absent,  after  repeated  search  by  both  smear  and  culture,  through  a 
month  or  more  of  examination.  Fm*ther  details  are  fomid  in  the  para- 
graphs on  Prophylaxis  (page  483) .    Examination  of  the  semen,  secured 


74  ACUTE  URETHRITIS 

in  a  condom,  worn  at  night,  which  soon  stimnlates  an  emission,  must 
always  be  the  hist  test.  Absohite  rehef  from  the  disease  is  present  when 
there  is  no  longer  any  infection  and  when  all  symptoms  are  absent  and 
no  chronic  or  comi)licating  lesions  appear. 

POSTERIOR  GONOCOCCAL  ACUTE  XJRETHRITIS. 

Significance. — Extension  of  the  organisms  into  the  posterior  urethra 
is  a  condition  of  great  clinical  importance,  owing  to  the  severity  of  the 
infection,  which  causes  invasion  beyond  the  compressor  urethrce  muscle 
into  the  posterior  urethra  and  owing  to  the  number  and  viciousness  of 
the  complications  usually  associated  with  it.  A  distinction  must  be 
drawn  between  real  infection  of  the  posterior  urethra  and  a  sympa- 
thetic congestion  without  infection,  such  as  is  i)robably  common  for  a 
day  or  so  in  every  case  of  severe  true  anterior  urethritis.  The  former 
has  a  definite  symptomatology,  but  the  latter,  only  temporary  urinary 
disturbance. 

Etiology. — The  etiology  is  the  same  in  predisposing  factors  as  in 
anterior  disease  and  the  exciting  factor  is  the  gonococcus,  with  or  with- 
out other  organisms.  The  extension  into  the  deep  urethra  by  the  organ- 
isms, ho\\'eA'er,  may  be  secured  alone  by  the  intensity  of  the  infection 
or  also  by  mechanical  means,  such  as  injections  im])roperly  or  too 
frequently  taken,  irrigations  too  concentrated  or  forcible  in  applica- 
tion, instruments  such  as  catheters  and  sounds  prematurely  passed, 
indirect  tramnatism  of  exercise  or  travel,  and  perhaps  most  common 
of  all  hypercongestion  of  sexual  excitement  and  dietetic  indiscretions. 

S3nnptoms. — Local  Subjective  Symj^toms. — These  have  their  onset 
at  the  end  of  the  first  or  second  week  of  establishment  of  vicious 
anterior  urethritis  or  later  in  the  less  severe  cases,  and  show  varieties 
of  intensity  from  simple  hj'peremia  to  florid  and  complicated  types. 
The  chief  symptoms  are  decreased  discharge  and  increase  of  frequency 
of  urination,  followed  by  tenesmus  and  augmented  pain  during  urina- 
tion or  seminal  emission  and  terminal  hematuria.  The  decreased 
discharge  is  due  to  temporary  withdrawal  of  the  blood  from  the  anterior 
urethra  to  the  new  zone  of  disease,  so  that  the  exudate  from  the  former 
is  for  a  brief  period  less  copious.  The  pollakiuria  is  due  to  the  direct 
in\ohement  of  the  mucosa  around  the  neck  of  the  bladder,  and  the 
tenesmus  rests  on  the  same  basis,  with  still  deeper  penetration,  followed 
by  spasm  of  the  sphincter  vesicae.  Terminal  hematuria  is  explained 
in  the  same  manner,  with  ruptured  capillaries  and  denuded  epithelium 
added.  Emissions  of  semen  are  much  more  frequent  than  in  anterior 
urethritis,  because  the  outlets  of  the  ejaculatory  ducts  and  the  prostate 
are  both  more  or  less  involved  and  their  pain  is  caused  by  all  the 
inflammatory  conditions  present. 

Systemic  Subjective  Symptoms. — These  are  alike  in  kind  as  but  more 
intense  in  degree  than  those  in  anterior  infections — namely,  anorexia, 
chills,  fever,  depression,  prostration,  and  pallid,  haggard,  worried 
appearance.    Nervous  irritability  is  common. 


POSTERIOR  GONOCOCCAL  ACUTE  URETHRITIS  75 

Local  Objective  Symptoms. — All  rest  on  the  urinary  and  rectal  exami- 
nation. Every  specimen  of  the  two  or  multiple  glass-test  is  turbid, 
owing  to  the  fact  that  the  pus  now  lies  throughout  the  canal  from 
sphincter  to  meatus  and  the  urine  of  the  first  glass  is  insufficient  to 
clear  the  urethra.  Often  the  last  glass  is  equally  as  or  more  turbid  than 
the  first  glass,  owing  to  the  fact  that  the  contraction  of  the  posterior 
urethura  in  carrying  the  urine  outward  expresses  more  pus  than  the 
first  flush  of  urine  washes  before  it.  The  last  glass  may  also  contain 
prostatic  elements  for  the  same  reason.  Rectal  examination  must 
reach  the  prostate,  seminal  vesicles  and  ampullse  of  the  vasa  deferentia 
as  any  or  all  these  structures  are  involved  at  least  in  secondary  con- 
gestion if  not  complicating  infection.  The  former  lesion  may  give  an 
almost  negative  finding  or  merely  softness,  succulence  and  slight 
tenderness,  with  increased  pus  in  the  test-glass  after  manipulation. 
The  sulcus  of  the  prostate  marking  the  general  course  of  the  urethree 
through  it  between  the  two  lateral  lobes  is  usually  the  point  first  and 
most  affected.  Infection  of  these  structures  belongs  to  the  subject  of 
Complications  under  which  it  is  treated. 

Termination. — Posterior  gonococcal  acute  urethritis  is  very  apt 
indeed  to  become  chronic,  especially  in  the  marked  cases,  and  therefore 
to  have  no  stage  of  termination,  strictly  speaking.  The  mild  cases, 
however,  last  a  short  time — one  or  two  weeks — and  then  subside  in 
much  the  same  manner  as  anterior  disease.  Pollakiuria,  tenesmus  and 
terminal  hematuria  all  gradually  subside,  likewise  sexual  excitement, 
with  emissions.  The  discharge  previously  decreased  in  the  anterior 
urethra  lights  up  anew  and  the  urine  finally  becomes  clear  except  in 
the  first  glass,  while  shreds  and  slugs  are  in  the  second  and  later  glasses 
derived  from  the  posterior  canal.  Irrigation  of  the  anterior  urethra 
copiously  may  so  cleanse  the  lining  that  all  the  glasses  will  be  practi- 
cally clear  when  the  posterior  lesion  has  fully  recovered. 

Complic  ations  .■ — Complications  of  posterior  gonococcal  acute  urethritis 
are  noted  for  their  frequency  and  presence  rather  than  for  their  rarity 
and  absence,  and  almost  always  initiate  lesions  of  chronic  tendency, 
such  as  urethrocystitis,  retention  of  urine,  funiculitis,  epididymo- 
orchitis,  seminal  vesiculitis  and  prostatitis.  Less  commonly  the  dis- 
ease extends  into  the  bladder  and  causes  cystitis,  ureteritis,  pyelitis 
and  pyelonephritis.  Absorption  of  organisms  and  toxins  leads  to  gono- 
coccal endocarditis,  sjaiovitis,  pleuritis  and  not  commonly  septi- 
cemia. The  occurrence  of  complications  is  due  to  the  complexity  and 
delicacy  of  the  mucosa  and  its  annexed  glands  and  organs  in  both 
sexes  and  to  the  penetrating  destructive  characteristics  of  the  gono- 
coccus  and  its  associated  organisms.  Variability  of  clinical  features  of 
all  such  complications  requires  their  discussion  in  a  separate  chapter, 
devoted  to  the  subject  of  Complications  (Chapter  II). 

Preventive  and  Abortive  Treatment. — Preventive  and  abortive  treat- 
ments are  in  the  strict  sense  impossible  beyond  carefid  and  judicious 
measures  applied  to  anterior  m-ethritis.  There  is  almost  always  at 
least  a  sympathetic  congestion  of  the  posterior  urethra  in  every  well- 


76  ACUTE  URETHRITIS 

established  example  of  the  anterior  lesion,  which  leads  to  mild  symp- 
toms of  brief  duration,  and  in  practically  every  severe  urethritis  the 
posterior  canal  becomes  acti^•ely  involved,  usually  Avithin  two  weeks 
ixnd  sonu'tinu's  a  few  days. 

Curative  Treatment.  Conservative  Method.— *S/«(/f^v. — The  usual  four 
periods  are  noted.  The  incubation  is  really  in  the  transit  of  the  infec- 
tion into  the  posterior  segment  of  the  canal,  and  is  so  masked  by  the 
anterior  symptoms  as  to  be  indistinguisliable,  and  hence  beyond  defi- 
nite treatment.  The  invasion  for  the  same  reason  is  practically  absent, 
although  mild  irritation  about  the  neck  of  the  bladder  is  a  forewarning 
and  may  be  regarded  as  marking  this  period;  but  by  no  means  invari- 
ably because  only  sympathetic  congestion  and  not  infection  may  be 
present.     Good  management  alone  is  the  required  treatment. 

The  details  of  management  are  described  in  full  in  Chapter  IX, 
on  the  General  Principles  of  Treatment  (page  483.) 

Local  subjective  symptoms,  already  stated  in  tlie  clinical  paragraphs, 
are  temporarily  decreased  discharge,  pollakiuria,  dysuria  and  tenesmus, 
all  due  to  irritation,  and  terminal  hematuria  and  sexual  emissions,  both 
due  to  extreme  congestion. 

The  irritation  and  congestion  indicate  cessation  of  blennorrhagics 
and  stimulants  and  return  to  sedatives,  diuretics  and  neutralizers 
such  as: 

I^ — Citrate  of  potash         30  grammes  (ounce  1) 

Tincture  of  hyoscyamus         .      .      .      .  8  to  12  grammes  (drams  2  to  3) 

Fluid  extract  of  kava  kava    ....  15  grammes  (ounce  5) 

Distilled  water  up  to 240  grammes  (ounces  8) 

Mix,  make  a  solution  and  mark: 

One  tablespoonful  in  a  half-glass  of  water  two  hours  after  eating  and  once  during 
the  night. 

When  vesical  irritation  is  marked  one  may  order: 

IJ — Fluidextract  of  triticum  repens     ....  45  grammes  (ounces  I5) 

Fluidextract  of  uva  ursi 45  grammes  (ounces  I2) 

Citrate  of  potash 15  grammes  (ounce    ^) 

Distilled  water  up  to '  .      .  120  grammes  (ounces  4) 

Mix,  make  a  solution  and  mark: 

One  to  two  teaspoonfuls  in  a  half-glass  of  water  two  hours  after  eating  and  once 
during  the  night. 

For  cases  with  great  pain  and  disturbance,  the  following  is  valuable: 

I^ — Fluidextract  of  triticum  repens      ...  45  grammes  (ounces  1  J) 

Fluidextract  of  uva  ursi 45  grammes  (ounces  1  J) 

Liquor  of  potash 15  grammes  (ounce  §) 

Tincture  of  opium 4  to  6  grammes  (drams  1  to  2) 

Distilled  water  up  to 120  grammes  (ounces  4) 

Mix,  make  a  solution  and  mark: 

One  teaspoonful  in  a  half-glass  of  water  every  three  or  four  hours  as  needed,  then 
three  times  a  day,  two  hours  after  meals. 

Systemic  subjective  and  objective  symptoms  have  been  stated  as 
intensifications  of  those  in  anterior  conditions:   Anorexia,  chills;  fever, 


POSTERIOR  GONOCOCCAL  ACUTE  URETHRITIS  77 

depression,  prostration,  nervous  irrita})ility,  pallor  and  worry.  "^I'lieir 
treatment  is  along  general  lines  of  good  management,  diet  and  suitable 
support.    Further  details  are  unnecessary. 

Local  objective  symptoms  are  the  discharge  figured  in  the  i)us  in  all 
glasses  of  the  multiple  glass  test  and  the  findings  on  rectal  examina- 
tion. Discharge  as  a  subjective  symptom  properly  })elongs  under  this 
heading  for  its  treatment.  The  question  of  local  treatment  in  pos- 
terior acute  urethritis  may  be  answered  as  follows :  If  the  disease  has 
followed  quickly  upon  anterior  treatment  it  is  well  to  regard  the  latter 
as  causative  through  undue  severity  or  frequency  and  posterior  meas- 
ures as  unwise.  If  the  posterior  disease  is  present  at  the  first  visit  or 
arises  in  the  absence  of  anterior  interference  it  may  be  regarded  as 
a  pathological  extension  and  as  an  indication  of  properly  selected 
treatment. 

Local  measures,  as  hand  injections  or  syringe-and-catheter  irriga- 
tions in  the  office,  are  in  all  cases  to  be  discontinued,  and  peremptorily 
must  be  in  severe  cases.  In  mild  attacks  hand  injections  may  be 
continued  at  greatly  reduced  strengths,  but  only  by  very  intelligent 
patients,  and  the  irrigations  are  preferably  boric  acid  water  or  normal 
salt  solution  for  the  benefit  of  the  heat.  Hydrotherapy  is  highly  advis- 
able in  the  form  of  ice-bags  to  the  perineum  and  pubic  regions,  and 
hot  or  cold  rectal  irrigations,  with  double  current  tubes,  permitting 
the  fluid  to  bathe  the  mucous  membrane,  or  with  the  psychrophore, 
which  applies  the  temperature  only  and  not  the  water,  or  with  simple 
enemata,  which  the  patient  takes  in  small  quantities,  holds  as  long 
as  possible  while  straddling  the  toilet,  and  gently  repeats  several  times 
at  each  sitting.  Such  enemata  are  least  advisable,  but  must  be  used 
by  patients  who  cannot  afford  the  rectal  tube  or  psychrophore.  Nor- 
mal salt  solution  at  105°  to  120°  F.  is  best  to  avoid  irritating  the  rectal 
mucosa  by  any  method. 

Hot  sitting  and  body  baths  increase  the  decongestion  instituted  by 
the  rectal  hydrotherapy.  Opium  suppositories,  grain  |  to  1,  may  be 
judiciously  used  in  the  right  type  of  patient  for  great  pain,  otherwise 
the  formula  with  laudanum  is  used.  Massage  and  electrotherapy  are 
both  contraindicated,  but  examination  of  the  prostate  is  advisable 
every  few  days  in  order  to  detect  its  earliest  involvement,  through 
enlargement,  tenderness,  tension,  edema  and  the  like.  Deep  instilla- 
tions of  nitrate  of  silver  solution,  1  in  1000  up  to  1  in  500,  may  be 
applied  through  a  16  French  soft-rubber  catheter  most  gently  passed 
into  the  prostatic  portion.  Tenesmus  and  bleeding  may  be  alarming 
and  severe.  Only  a  few  drops  should  be  used,  and  not  repeated  unless 
benefit  results.  The  weaker  solution  is  the  better  for  the  first  treat- 
ment. 

Stage  of  Decline. — ^This  period  is  as  in  anterior  acute  urethritis, 
that  of  Nature's  success  against  the  disease  and  the  time  of  local  treat- 
ment, and  its  management  remains  the  same  except  that  diet  may  be 
slightly  increased  and  in  the  mild,  uncomplicated  cases  the  patients 
may  go  outdoors,  but  in  the  severe  cases  remain  resting  in  easy  chairs^ 


78  ACUTE  URETHRITIS 

and  in  the  complicated  cases  arc  still  confined  to  bed.  The  ingestion 
of  fluids  is  still  alh^wed  in  sliohtly  increasing  quantities.  Systemic 
administration  is  rolietl  on  to  relieve  all  the  systemic  subjective  symp- 
toms and  most  of  the  local  subjective  symptoms.  Such  as  are  not 
reached  by,  these  methods  are  benefited  by  the  treatment  of  the  dis- 
charge. Blennorrhetics  are  again  used  for  stinnilant  efl'ect,  but  never 
to  extremes,  and  always  associated  with  urinary  antise])tics  as  ])reven- 
tives  of  infection  of  the  bladder  by  the  irrigation  of  this  viscus. 

The  local  treatment  is  in  the  form  of  weak  and  then  slowly  increased 
fornuilas,  previously  given  for  hand  injections,  made  first  once  or 
twice  and  then  more  frequently  each  day,  and  in  the  form  of  syringe- 
and-catheter  irrigations,  preferably  in  the  reclining  position,  beginning 
with  normal  salt  solution  and  boric  acid  water,  then  continuing  with 
the  milder  antiseptics  already  detailed  and  ending  with  the  stronger 
solutions.  The  urethra  is  first  flushed  by  urination  and  then  its 
anterior  segment  is  tlioroughly  cleansed,  and  last  a  small  soft-rubber 
catheter  is  very  gently  passed  into  the  bladder,  which  is  immediately 
thoroughly  irrigated  in  order  to  prevent  infection  and  left  comfort- 
ably distended  so  that  the  patient  washes  his  posterior  urethra  with 
the  antiseptic  fluid  exactly  as  with  urine.  After  further  decline,  and 
with  a  tendency  to  indolence,  mild  and  ascending  strengths  of  instil- 
lations are  applied  to  the  deep  urethra,  always  without  tenesmus 
resulting.  Nitrate  of  silver  is  the  choice  in  strengths  from  1  to  10,000 
or  1  in  5000,  slowly  increasing  to  1  in  1000  or  more  cautiously  1  in  500. 
Failure  with  these  measures  forewarns  of  the  chronic  period,  which 
is  discussed  in  subsequent  paragraphs. 

Stage  of  Termmation. — This  period  in  uncomplicated  cases  under 
expectant  treatment  is  reached  in  from  a  few  days  to  two  or  three 
weeks,  but  in  uncomplicated  severe  cases  the  chronic  lesions  appear 
and  persist  for  weeks  or  even  months.  Complications  always  involve 
long  continuation,  and  their  presence  is  detected  by  rectal  and  urethral 
exploration,  urethroscopy  and  cystoscopy,  and  their  treatment  belongs 
to  su])sequent  paragraphs  on  each  separate  complication. 

Complications  are  fully  treated  each  under  its  own  heading  in 
Chapter  II,  pages  82  and  106. 

Retention  of  urine  may  be  classed  either  as  a  symptom  or  a  com- 
plication, and  should  be  mentioned  here.  It  should  be  managed  by 
absolute  rest  in  bed,  free  e^•acuation  of  the  bowels  and  very  light 
fever  diet.  Systemically,  morphin,  with  the  needle  or  a  Dover's 
powder  by  mouth  or  an  opium  suppository,  in  selected  cases,  is 
given  as  an  antispasmodic  and  sedative,  and  locally  heat  as  a  decon- 
gestant is  applied  by  urethral  irrigations  of  boric  acid  water,  and  pro- 
longed sitting  and  body  baths  and  rectal  irrigations  almost  always 
relieve,  so  that  the  patient  may  urinate  into  the  bath  water.  Instru- 
mentally  a  size  14,  16  or  18  French  soft-rubber  catheter  may  be  passed, 
with  great  gentleness,  to  avoid  all  spasm,  and  the  bladder  emptied,  in 
whole  if  moderately  filled,  but  in  part  if  much  distended,  in  order  to 
avoid  passive  hemorrhage  from  sudden  release  of  pressure.     With  the 


POSTERIOR  GONOCOCCAL  ACUTE   URETHRITIS  79 

catheter  in  place  the  viscus  must  be  irrigated  to  avoid  inf(!ction,  using 
potassium  permanganate,  1  in  8000  to  1  in  4000,  or  nitrate  of  silver, 

1  in  10,000  to  1  in  5000,  or  one  of  the  newer  silver  salts,  such  as  argyrol, 

2  to  5  per  cent.  A  little  of  the  weak  solution  must  be  left  in  the 
bladder  if  the  distention  was  marked,  in  order  to  avoid  passive  hemor- 
rhage. The  catheter  is  slowly  withdrawn,  and  at  the  moment  outflow 
ceases  its  eye  is  in  the  deep  urethra,  where  a  little  nitrate  of  silver  solu- 
tion, 1  in  1000,  may  be  deposited  as  a  corrector  of  the  edema.  Pre- 
vention of  relapse  requires  repetition  of  the  Dover's  powder  or  supposi- 
tory, hot  pack,  baths,  rectal  irrigations  and  urethral  irrigations,  while 
prevention  of  onset  rests  with  proper  care  of  the  posterior  acute 
urethritis;  but  the  retention  may  supervene  notwithstanding  every 
precaution  and  measure. 

Irrigation  Method.^ — Cautions.  —  Undue  force  of  the  irrigation  may 
penetrate  the  crypts  of  the  mucosa,  the  acini  of  the  prostate  with  their 
ducts  and  the  ejaculatory  ducts,  of  which  the  majority  face  forward 
and  all  are  minute  and  tender  structures.  Chemical  inflammation 
and  positive  traumatism  even  to  rupture,  similar  to  the  rupture  of 
the  urinary  bladder  by  distention,  may  result,  thus  causing  compli- 
cations directlj^  Undue  frequency,  excessive  concentration  and  idio- 
syncrasy of  the  patient  to  the  solution  may  also  cause  secondary  irri- 
tation and  add  to  the  inflammation.  It  is  'possible  to  do  as  much 
damage  with  a  stream  of  irrigation  as  with  an  instrument — both 
unskilfully  handled. 

Definition,  purposes  and  preliminaries  are  the  same  as  in  the  irriga- 
tion method  in  the  anterior  urethra  and  vary  from  this  only  as  to  the 
site.  It  may  be  used  as  a  preventive  of  infection  after  the  passage  of 
instruments,  but  is  probably  less  advisable  than  the  passing  of  a  soft 
catheter  for  the  purpose,  and  is  much  less  convenient  than  the  author's 
irrigating  sounds  and  similar  instruments,  which  permit  the  bladder 
to  be  filled  at  the  one  incursion  and  before  withdrawal.  The  patient 
should  always  urinate  in  the  presence  of  the  surgeon  before  the  irriga- 
tion. 

Internal  measures  are  the  same  as  in  anterior  irrigation,  with  the 
detail  that  blennorrhetics  are  somewhat  more  reservedly  employed. 

Local  measures  are  of  three  kinds:  (1)  syringe-and-catheter  method, 
(2)  Janet-Valentine  method,  (3)  Chetwood  double-current  method. 
The  application  of  each  has  the  following  restrictions: 

Syringe-and-catheter  posterior  irrigation  is  undoubtedly  the  safest  in 
the  posterior  urethra,  and  is  defined  by  the  passage  of  a  catheter  into 
the  posterior  urethra  and  bladder  f  oho  wed  by  irrigation  of  both  parts. 
Its  preliminaries  are  the  standard  preparation  of  the  patient,  com- 
plete sterilization  of  all  instrmnents  and  utensils,  evacuation  of  the 
bladder  by  the  patient  before  passing  the  catheter  and  irrigation  of 
the  anterior  canal  before  the  posterior  portion  is  invaded.  Its  equip- 
ment is  an  assortment  of  soft-rubber,  velvet-eye  or  new  smooth  wo\-en 
catheters,  sizes  14,  16  and  18,  French,  a  150  c.c.  Janet-Frank  syringe 
(which  is  preferred  to  the  irrigating  jar),  a  Wolbarst  or  other  basin 


80  ACUTE  URETHRITIS 

and  assorted  towels  and  similar  dressings.  Its  technic  is  the  passage 
of  the  catheter,  cleansing  the  anterior  urethra  as  it  progresses  and  then 
without  the  Huid  running  the  posterior  urethra  and  bladder  are  entered 
so  gently  that  no  spasm  occurs.  The  bladder  is  filled  to  comfort  and 
evacuated  several  times  and  left  filled  at  the  last  step.  As  the  catheter 
is  withdrawn  the  posterior  m-ethra  may  recei^•e  instillations  or  mild 
irrigation  if  no  spasm  is  present,  and  finally  it  is  washed  by  ha^'ing 
the  patient  pass  the  antiseptic  fluid  left  in  the  bladder.  Force  is 
unnecessary  beyond  that  for  filling  the  bladder,  and  duration  ends 
with  several  distentions  of  from  150  to  500  c.c.  always  W'ithin  toler- 
ance, and  frequency  is  like  that  of  anterior  irrigation,  at  first  daily, 
then  every  other  day  and  finally  temperature  rests  on  comfort,  but 
ranges  from  100°  to  120°  ¥.,  by  the  thermometer.  Fluids  are  the 
standard  solutions  and  combinations  already  detailed. 

Valentine-Janet  posterior  irrigation^  in  the  prostatic  urethra  has  the 
same  equipment,  preparation,  preliminaries  and  postures  as  in  the 
anterior  treatment.  Fully  sterilized  instruments,  utensils  and  external 
organs  and  urination  of  the  patient  in  the  presence  of  the  urologist  are 
basic  principles.  Its  technic  requires  position^at  the  side  of  the  patient, 
irrigation  of  the  penis  and  external  genitals  and  then  tight  ap])osition 
of  the  nozzle  into  the  meatus,  so  that  outflo\\"  is  prevented.  The  force 
is  sloAA'ly  increased  by  raising  the  irrigator  up  to  a  head  of  six  to  eight 
feet  as  the  urethra  distends.  While  the  patient  breathes  deeply  and  tries 
to  urinate,  the  fluid  is  felt  to  start  into  the  bladder  by  both  the  urologist 
and  the  patient.  Then  the  force  of  the  fluid  should  be  decreased  by 
pressure  on  the  stopcock  and  checked  before  pain.  The  basin  and 
nozzle  are  now  removed  and  the  patient's  genitals  dried.  He  then 
passes  the  contents  of  his  bladder  into  test-glasses,  either  sitting  or 
standing,  at  once  or  after  waiting,  according  to  the  presence  of  infection 
in  the  bladder.  Duration  is  only  to  fill  the  bladder  with  from  150  to 
500  c.c,  once  or  several  times,  according  to  the  condition  of  the  organ 
and  irritation  and  tolerance.  The  latter  increases  with  experience  in 
the  patient  and  gentleness  in  the  urologist.  Temperature  rests  on  the 
same  basis,  varying  from  100°  to  120°  F.,  by  the  thermometer.  Fre- 
quency begins  with  once  a  day  and  then  every  other  day,  and  at  each 
treatment  several  distentions  of  the  bladder  are  possible  imtil  the 
return  flow  is  clear  of  pus,  when  a  final  distention  is  left  for  evacuation. 
Spasm  is  usually  overcome  by  starting  with  a  fully  empty  bladder, 
reducing  the  force  of  the  stream,  diverting  attention  of  nervous 
patients  and  using  the  reclining  position.  The  fluids  are  the  duplicates 
of  formuUe  previously  described. 

Chetwood  double-current  posterior  irrigation  shows  no  changes  in  the 
deep  m-ethra  from  that  in  the  anterior  portion  as  to  all  the  preliminaries 
discussed  under  that  subject.  Sterilization  of  all  instruments  and 
utensils  and  passing  of  the  urine  in  the  urologist's  office  are  axioms. 
Force  from  an  elevation  of  the  irrigator,  six  to  eight  feet,  is  necessary 

'  Loc.  cit. 


POSTERIOR  GONOCOCCAL  ACUTE  URETHRITIS  81 

and  the  technic  is  the  same  as  in  the  Valentine  method,  with  the  added 
advantage  of  the  double  current  cut-off,  with  which  the  fluid  is  applied 
to  the  sphincter  muscle  until  the  bladder  is  filled  with  small  quantities 
at  first  and  then  with  larger  supplies  up  to  tolerance,  and  always  with 
gentleness  to  avoid  spasm.  Final  details,  such  as  duration,  temperature, 
frequency  and  repetitions,  are  the  same  as  in  the  other  procedures. 
There  is  no  change  from  the  standard  fluids  designated  in  earlier 
paragraphs. 

Aftertreatment  and  cure  are  the  same  in  posterior  gonococcal  acute 
urethritis  as  briefly  noted  under  the  heading  of  Anterior  Gonococcal 
Acute  Urethritis  (page  70) .    Further  note  is  therefore  here  unnecessary. 

Treatment  of  Nongonococcal  Urethritis. — The  brevity  of  this 
subject  in  this  work,  owing  to  the  fact  that  gonococcal  urethritis  is 
presented  as  the  typical  inflammation  in  all  its  phases,  has  made  it 
advisable  to  consider  the  treatment  of  nongonococcal  urethritis  of 
both  acute  and  chronic  forms  after  the  treatment  of  gonococcal  chronic 
urethritis  as  part  of  Chapter  IV. 


CHAPTER  II. 

COIMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS. 

General  Considerations. — Anterior  and  posterior  acute  urethritis  have 
acute  complications  which  possess  distinct  tendency  to  become  chronic, 
owing  to  the  coniplexity  and  dehcacy  of  the  organs  and  the  destructive 
and  penetrating  faculties  of  those  organisms  which  commonly  provoke 
the  severe  infections,  notably  the  pyogenic  and  gonococcal  forms, 
in  pure  or  associated  culture.  On  the  other  hand,  complications  may 
arise  in  any  of  the  other  nongonococcal  urethrites  in  patients  of  lowered 
vitality  and  with  intense  invasion.  Complications  are  also  not  uncom- 
mon in  relapsing  nongonococcal  disease,  such  as  catarrhal  and  diathetic, 
while  they  are  very  common  indeed  in  relapsing  gonococcal  acute 
urethritis. 

General  Clinical  Features. — In  all  acute  complications  of  acute 
urethritis  of  any  origin  whatever  the  clinical  characters  are  much  the 
same  according  to  the  special  part  involved.  Inasmuch,  however,  as 
gonococcal  acute  urethritis  is  most  prone  to  develop  the  complications, 
and  as  their  symptoms  are  the  most  t^Tpical  and  severe,  it  is  best  to 
regard  them  as  the  standard  of  comparison  for  the  other  forms.  The 
best  is  the  clinical  classification  into  acute  and  chronic  as  to  course, 
and  anterior,  posterior  and  anteroposterior  as  to  location.  The  chronic 
complications  belong  to  the  subject  of  chronic  uretlu-itis,  hence  only 
the  acute  forms  will  be  considered  in  this  chapter. 

I.  COMPLICATIONS  OF  ANTERIOR  GONOCOCCAL  ACUTE 
URETHRITIS. 

Varieties. — Two  general  subdivisions  are  recognized:  (a)  local, 
affecting  the  urogenital  organs  alone,  and  {b)  systemic,  affecting  the 
body  at  large.  In  anterior  acute  disease  systemic  complications  are 
rarely  seen,  are  somewhat  more  common  in  posterior  acute  urethritis 
and  still  more  usually  occur  in  anteroposterior  chronic  urethritis.  For 
this  reason  they  will  be  discussed  as  essential  to  posterior  lesions  rather 
than  anterior  disease.  The  local  complications  had  best  be  arranged 
in  their  anatomical  order,  and  in  the  nature  of  things  are  only  sexual 
and  urinary  in  their  location.  They  are:  ])himosis,  ])arai)himosis, 
lymphangeitis,  lymphadenitis,  littritis,  folliculitis,  cowperitis  with  reten- 
tion and  co\\'peritis  without  retention.  Complications  in  the  sexual, 
urinary  or  general  systems  arising  cephalad  to  the  triangular  ligament 
are  considered  under  posterior  urethritis  (pages  115,  201), 


PHIMOSIS  AND  PARAPHIMOSIS 


83 


A.  Urogenital  Group. 
1.  Sexual  Forms. 

PHIMOSIS  AND  PARAPHIMOSIS. 

Definition  and  Etiology.^ — Phimosis  and  paraphimosis  are  two  compli- 
cations which  are  caused  by  a  long  and  a  tight  foreskin.  Redundant 
prepuce  leads  to  balanitis  and  balanoposthitis,  while  the  tightness 
adds  phimosis  and  irreducibility  of  a  retracted  tight  prepuce  causes 
paraphimosis.  In  all  these  three  the  inflammatory  lesions  are  much 
the  same. 

Symptoms.^ — The  subjective  symptoms  of  phimosis  are  ardor  urinse 
within  the  cavitv  of  the  foreskin  and  not  the  course  of  the  urethra,  often 


Fig.  16. — Method  of  reduction  of  reducible  acute  paraphimosis,  showing  position 
of  foreskin  and  glans,  respectively,  witliin  the  grasp  of  the  fingers  and  pressure  of  the 
thumbs.     (Taylor.i) 

with  "ballooning"  of  the  foreskin,  due  to  back  pressm-e  during  m-ination. 
Pain  in  the  foreskin  and  glans  is  due  to  excoriation  of  the  lining,  reten- 
tion and  decomposition  of  urine,  pressure  of  the  edema,  tension  during 
erection  and  irritation  by  contact  with  clothing  and  fingers.  Objec- 
tive symptoms  of  phimosis  are  tenderness  over  the  glans  penis  away 
from  the  course  of  the  urethi-a,  generalized  over  the  whole  glans  and 
the  foreskin  and  not  localized  as  in  chancrous  phimosis.  Retractible 
foreskin  reveals  a  tj^jical  balanoposthitis,  with  redness,  excoriation, 
maceration,  edema  and  sometimes  lymphangitis,  everywhere  distrib- 
uted and  a  discharge  which  wells  up  from  the  recesses  and  folds  about 
the  corona   and   is  therefore  distinct   from  that  which  oozes  from 

1  Loo.  cit. 


S4  COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

the  uivtlira.  lrrotra(.'til)k'  foreskin  rt'ciuiri's  dilatation  of  the  outlet 
and  eavity  with  a  thive-])hide  nasal  spt'cnhnn  and  illumination  with 
a  urethroseopie  lamp  or  examination  ^\■ith  a  Chetwood  urethroscope, 
and  will  show  much  the  same  features.  The  edema,  as  a  rule,  is  local- 
ized to  the  foreskin  and  solans  and  not  to  tlie  penis  as  a  whole;  excep- 
tionally, however,  the  edema  is  generalized  throughout  the  penis  or  a 
large  })art  of  it.  Lymphangitis  may  often  be  traced  along  the  dorsum 
and  sides  of  the  organ  into  the  groins,  where  lymphadenitis  may  be 
present,  both  with  moderate  tenderness. 

rarai)himosis  is  regarded  as  of  two  varieties:  acute  reducible  or 
without  gangrene,  and  acute  irreducible  or  with  gangrene.  The 
reducible  form  is  characterized  by  enormous  infiltration  of  the  foreskin 
with  serum,  so  that  it  retracts  beyond  the  glans  and  remains  in  this 
situation  as  a  rather  imiformly  distributed  mass  of  edema  without  any 
pressure  or  necrosis.  The  irreducible  tyj)e  is  characterized  by  a  definite 
fibroelastic  band  of  tissue,  not  unconunonly  constituting  the  original 
outlet  of  the  redimdant  foreskin,  which  when  passed  beyond  the  glans 
is  normally  sufficiently  tight  to  constrict,  and  to  set  up  edema  of  the 
parts  distal  to  it,  and  thereafter  through  the  pressure  of  both  the  band 
and  the  edema  to  cause  localized  ulceration  and  gangrene.  Rarely 
death  of  the  glans  in  part  or  whole  is  seen. 

The  objective  symptoms  are  that  the  retracted  foreskin  constricts  the 
corona.  The  pressure  leads  to  congestion,  lividity  and  edema  of  the 
glans  and  then  of  the  constricting  band.  Ulceration,  as  a  rule,  occurs 
only  in  the  foreskin  at  its  tightest  point,  so  that  Nature's  tendency 
is  spontaneous  di\ision  of  the  fibers  and  release  of  the  glans.  Reten- 
tion of  urine,  except  reflexly,  does  not  occur.  Beneath  the  folds  of  the 
foreskin,  and  especially  within  the  pocket  behind  the  constriction,  a 
characteristic  retention  pus  is  secreted,  produced  by  balanoposthitis. 
The  characteristic  organisms  of  this  pus  decide  the  nature  of  the 
infection. 

The  subjective  symptoms  are  the  pain  due  to  the  constriction, 
inflammation,  and  retained  pus  and  fear  through  the  unnatural,  severe 
congestion,  lividity  and  swelling  of  the  glans. 

Diagnosis. — Phimosis  in  its  history  presents  the  acute  swelling, 
irretractible  foreskin  which  was  previously  retractible,  and  in  chronic 
cases  a  foreskin  which  could  never  be  reduced  in  which  inflammation 
is  persistent  or  acutely  apparent.  Paraphimosis  in  its  history  is 
never  chronic,  always  acute,  but  may  appear  during  a  chronic  ureth- 
ritis with  acute  exacerbation.  Subjective  symptoms  are  chiefly  those 
of  the  balanitis,  posthitis  and  balanoposthitis,  which  are  discussed 
under  the  next  heading,  and  their  origin  in  urethritis,  ulcers  or  trau- 
matism may  sometimes  be  described  by  the  patient.  Objectively  the 
condition  of  the  foreskin  and  its  lining  is  demonstrated  by  the  palpation 
and  inspection,  with  or  without  meatoscopes  or  urethroscopes,  within 
the  cavity  of  the  foreskin,  if  irretractible.  Laboratory  findings  are 
most  important  and  must  demonstrate  the  gonococcus  from  within  the 
urethra  and  the  cavity  of  the  foreskin  recovered  from  the  latter,  with 


PHIMOSIS  AND  PARAPIIIMOHIH 


85 


the  platinum  loop  and  endoscopic  tiihc,  at  points  of  maceration  or 
excoriation  of  the  modified  skin.  Other  organisms  causinjf  this  com- 
pHcation  must  be  excluded. 

The  importance  of  laboratory  findinjijs  is  most  emphatic  in  all  cases, 
and  more  so  in  the  extragenital  complications,  arul  must  include  in 
bacteriology  smear,  culture  and  animal  inoculation  and  in  hematology 
the  various  fixation  tests,  of  which  two  are  recognized,  syphilitic  and 
gonococcal,  with  tuberculosis  in  the  course  of  development  and  j^rob- 
ably  those  of  other  diseases  to  be  added  later. 


Fig.  17. — Author's  case  of  phimosis  due  to  advanced  cardiorenal  disease.  This 
patient  was  in  the  last  stages  of  cardiovascular  and  renal  disease  with  marked  edema 
of  both  lower  extremities  and  the  lower  half  of  the  abdomen.  The  penis  was  phimotic 
and  the  scrotum  was  enlarged  by  edema  to  three  or  four  times  its  natural  size.  Marked 
balanoposthitis  was  absent.  On  account  of  ob'\'ious  intraabdoniinal  pressure  and 
muscular  atony  the  truss  was  not  removed  for  the  photograph. 


In  diagnosis  treatment  must  result  in  prompt  relief  of  the  balano 
posthitis  independently  of  the  urethritis.  The  following  subjects 
further  clear  up  the  differential  diagnosis :  Clii'onic  phimosis  presents 
frequent  acute  attacks,  and  finally  the  persistent  or  relapsing  condition 
resting  on  anatomical  defect  or  such  diseases  as  diabetes.  The  symp- 
toms  are  usually  a  thickened  irreducible  skin,  with  cracks  and  fissures 


86  COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

about  the  opening.  The  anatomical  defect  may  be  the  only  symptom 
in  patients  who  have  escaped  inliammation  within  the  foreskin. 

Treatment  of  Gonococcal  Acute  and  Chronic  Phimosis.-  Thimosis  and 
l)arai)liini(»sis  arc  in  their  signiticance  usually  minor  comi)lications, 
but  may  become  major  by  existing  lymphatic  and  other  sequels. 

Prevention  is  circumcision,  a  racial  custom  in  a  large  portion  of  the 
human  faiuily  aiul  indicated  whenever  there  has  been  repeated  non- 
gt)n()C()ccal  balanitis,  which  ])roves  an  easily  ali'ected  modified  skin 
lining  the  foreskin  anil  covering  the  glans,  and  whenever  the  ])himosis 
is  a  real  congenital  defect  and  whenever  paraphimosis  has  occurred. 
Abortive  treatment  consists  ()nl>'  in  energetic  measures  at  the  earliest 
sign  of  swelling  or  discharge  of  the  same  kind  as  curative  treatment. 

Curative  Treatment. — Curative  treatment  is  synoinjnous  with  symp- 
tomatic and  is  interested  in  the  ardor  urinoe,  ])ain,  tenderness,  edema, 
inflajnmation,  retractibility  and  irretractibility  of  the  foreskin. 
Cleanliness,  rest  in  bed,  continued  attention  to  diet  and  drink  arc  the 
management  and  a\'oid  any  increase  in  the  inflammation.     Preputial 


Fig.  18. — Author's  subpreputial  irrigation  (original.)  The  putieut  is  draped  in  the 
standard  method  (Fig.  1.5)  and  then  a  female  silver  catheter  mounted  in  the  Valentine 
cut-off  is  passed  under  the  foreskin  of  the  penis,  held  for  cleanliness  and  against  all 
splash  in  gauze,  while  the  high  head  of  fluid  l)alloons  and  washes  out  the  prepuce  into 
the  Wolbarst  basin. 

irrigations,  hot  penile  baths,  and  when  the  foreskin  is  again  retractible, 
hot  washings  are  included  under  hydrotherapy  for  the  infection  and  its 
result.  The  author's  method  of  irrigating  the  foreskin  is  shown  in  Fig. 
18,  and  will  be  found  most  efficient  with  the  usual  antiseptic,  astringent 
and  stimulating  solutions.  Its  technic  is  fully  detailed  on  page  97, 
under  the  treatment  of  Balanitis. 

The  means  are  irrigations  and  hand  injections,  with  the  subpreputial 
syringe  with  a  long  tip  (Fig.  7,  D  and  E),  with  exactly  the  same  drugs 
as  employed  for  urethral  treatment,  .such  as  hot  potassium  perman- 
ganate, 1  in  4000  to  1  in  1000,  which  in  the  author's  opinion  is  the  best 
of  all  for  the  foreskin,  or  nitrate  of  silver,  1  in  5000  to  1  in  2000,  or 
w^eak  bichloride  of  mercury,  1  in  5000  to  1  in  2000.  Medicinal 
measures  in  astringent  and  antiseptic  fluids  at  first  twice,  then  once, 
daily  using  from  a  half  to  a  whole  gallon  each  time.    If  the  foreskin  is 


PHIMOSTS  AND  PARA  PUT  MOSIS  87 

irretractible  it  is  tlic  only  means  avai]a}>l(;  aided  by  hand  injections  by 
the  patient  in  the  intervals,  using  only  the  long,  soft-rubber  or  glass- 
tipped  syringe  for  the  foreskin.  If  the  foreskin  is  or  becomes  retractible 
the  glans  may  be  painted  with  nitrate  of  silver  solution,  1  in  250  to 
1  in  125,  every  day,  and  the  penis  soaked  in  a  tum})ler  of  hot  perman- 
ganate of  potash  solution,  1  in  4000  to  1  in  1000,  all  according  to  reac- 
tion; or  wet  dressings  every  two  to  four  hours  of  aluminum  acetate, 
black  wash,  bichloride  of  mercury,  1  in  5000,  or  lead  and  opium  wash 
are  serviceable  against  edema  and  a  tendency  to  cellulitis.  Relapse  is 
guarded  against  by  careful  washing,  dressing  and  powdering  of  the 
glans  and  foreskin  during  the  rest  of  the  urethritis.  A  good  powder  is 
the  following: 

I^ — Thymol  iodide, 

Boric  acid, 

Bismuth  subgallate equal  parts 

Mix,  make  a  fine  powder  and  mark : 

Apply  locally  three  times  a  day,  washing  the  old  powder  off  carefully  each  time. 

Surgical  measures  are  nonoperative  and  operative.  Among  the 
nonoperative  means  are  the  irrigations  and  applications  through  the 
short  urethroscope  or  meatoscope  already  spoken  of.  The  operative 
step  is  circumcision  performed  by  the  following  technic:  Circumcision 
should  be  accepted  as  a  preventive  in  every  male,  and  in  the  selection 
of  case  is  applied  to  all  rebellious  cases  of  chronic  phimosis.  The 
instruments  and  supplies  include  a  phimosis  clamp,  scalpel,  scissors, 
forceps,  hemostats,  ligatures,  needles  and  dressings  and  the  prepara- 
tion of  the  field  is  irrigation  and  washing  with  soap  and  water  and  of 
the  patient  is  for  a  minor  operation  under  local  anesthesia  in  most 
adults  and  adolescents  and  general  anesthesia  in  small  children.  The 
posture  is  supine  and  the  glans  is  the  one  landmark,  and  must  not  be 
injured.  It  is  protected  by  stretching  the  foreskin  after  anesthesia 
so  that  it  may  be  retracted  and  its  relation  with  the  glans  determined, 
which  in  children  is  often  that  of  adhesion,  requiring  freeing.  There 
are  two  methods,  the  clamp  and  the  open.  In  the  clamp  method, 
the  clamp  is  applied  in  the  middle  line,  slightly  obliquely,  in  order  to 
spare  the  frenum  and  give  a  good  posterior  flap.  The  incision  is  made 
either  distal  to  the  clamp  or,  as  the  author  prefers,  proximal  to  it, 
drawing  the  foreskin  forward,  dividing  it,  layer  by  layer,  and  catching 
each  prominent  bloodvessel  before  it  is  divided,  spm'ts,  retracts  into 
the  cellular  tissue  and  starts  a  hematoma.  One  side  at  a  time  is  thus 
divided  from  the  outer  to  the  inner  skin.  When  the  foreskin  is  ablated 
all  bleeding  is  stopped,  the  inner  flap  trimmed  if  necessary  and  then 
the  edges  are  sutured  with  fine  silk  or  horsehair  in  the  adult,  but  fine 
catgut  in  the  child,  beginning  by  uniting  the  freniun  with  raphe  and 
then  the  midpoints  on  the  dorsum.  These  sutures  are  left  long  and 
held  by  the  assistant  to  support  the  organ  in  the  vertical  position  and 
appose  the  cut  edges  for  the  other  stitches,  placed  every  quarter-mch 
with  great  care  not  to  infold.  The  dressing  is  a  wick  of  iodoform 
gauze  held  against  the  suture  line  by  the  long  ends  of  the  stitches  tied 
over  it. 


88  COMPLICATIOXS  AXD  SEQUELS  OF  ACVTE  URETHRITIS 

Tlu'  (>]>eii  mt'thod  omits  tlio  daiii]).  and  after  all  the  f()ivji;()in»>'  pre- 
liminarios  makes  a  dorsal  inc-ision  to  the  corona  and  then  trims  and 
removes  the  two  flaps  down  to  the  frenum.  The  other  steps  of  the 
o])eration  dnplicate  those  already  given. 

The  innnediate  aftertreatment  is  to  inspect  for  abont  an  honr 
for  bleeding  and  hematoma  and  to  kee])  the  organ  sn])i)orted  on 
cotton  and  ])roteeted  from  the  weight  of  bed-clothing.  In  children 
the  application  of  boric  acid  ointment  prevents  wetting  the  dressing 
with  urine.  The  adnlt  should  be  directed  not  to  soil  the  dressings  in 
any  way.  If  the  case  is  ambulant,  a  ])ad  of  cotton  is  ])laced  n])on  the 
abdomen  to  receive  the  ])enis  and  another  upon  the  penis  itself,  and 
over  all  a  well-fitting  prize-fighter's  cotton  trunk  is  worn.  In  order  to 
urinate  the  patient  must  remove  and  then  replace  this  dressing.  The 
remote  aftercare  allows  the  catgut  stitches  in  children  to  dro])  away, 
but  the  silk  or  horsehair  in  adults  to  be  cut  out  on  the  seventh  to  the 
ninth  day  and  suitable  stimulating  dressings  to  be  applied  to  granu- 
lating spots.  The  glans  often  remains  extremely  sensitive  for  many 
weeks  in  adults  and  must  be  soothed  with  ointment  and  cotton. 

Cure  in  nonoperative  cases  is  the  relief  of  the  edema  and  infection 
and  the  restoration  of  retractibility  of  the  foreskin,  which  is  always 
possible  except  in  cases  of  congenital  abnormality. 

The  cure  in  operative  cases  should  show  a  penis  with  the  glans  fully 
exposed  but  with  the  stump  of  the  foreskin  not  tight  but  slightly 
loose  behind  the  corona  without  cohering  the  same. 

Treatment  of  Gonococcal  Acute  Paraphimosis. — K^ignificance,  usually 
of  minor  importance,  occasionally  major  through  ulceration  and  local 
gangrene.  Prevention  directs  no  attempt  at  retraction  of  the  foreskin 
when  either  it  or  the  glans  has  been  obviously  inflamed  and  suggests 
prom])t  and  proper  attention  to  a  phimosis  so  that  the  paraphimosis 
will  not  develop.  Immediate  replacement  of  a  retracted  foreskin, 
showing  constriction  back  of  the  glans,  with  swelling  and  edema,  is 
the  only  abortive  measure,  and  is  done  by  massage,  as  shown  in  Fig. 
1()  and  the  following  paragraphs: 

Ciirafire  Treaiment. — Curative  treatment  requires  cleanliness,  rest 
in  bed,  with  the  penis  supported,  and  nonirritating  diet  and  drink 
as  the  hygiene  against  increasing  any  of  the  factors  of  inflammation 
and  ulceration.  Decongestion  is  found  in  hot  antiseptic  penile  baths 
and  hot  sitting  baths  among  the  physical  methods,  and  digital  reduction 
of  the  deformity  is  the  massage  of  these  cases.  Local  wet  dressings 
of  hot  lead  and  opium  wash,  aluminum  acetate  or  bichloride  of  mercury, 
1  in  5000,  for  sedative,  antiseptic  and  astringent  effects,  introduce  the 
medicinal  measures.  Early  cases  may  be  reduced  by  massage  in  the 
following  nonoperative  surgical  procedure:  edema  is  gently  pressed 
from  the  glans  and  foreskin,  so  that  each  becomes  soft  instead  of  tense. 
Acupuncture  of  the  foreskin,  with  a  needle  under  antiseptic  precau- 
tions, may  be  necessary  for  the  evacuation  of  serum.  The  two  thumbs 
are  then  placed  against  each  other  for  support  on  the  glans  while  the 
two  index  and  middle  fingers  seize  respectively  the  dorsum  and  venter 


BALANITIS,  POSTIIiriS  AND  BALANOPOSTHITIS  89 

of  the  penis  well  back  of  the  constricting  band.  By  j)iishing  the  glaris 
into  the  ring  of  the  paraphimosis  and  pulling  the  ring  over  the  glans  at 
one  and  the  same  time,  a  coordinated  motion  of  thumbs  and  fingers 
toward  one  another,  the  paraphimosis  will  often  be  reduced.  The  con- 
stricting band  must  finally  be  felt  free  of  the  glans  in  the  foreskin 
in  front  of  the  meatus.  An  antiseptic  wet  dressing  should  be  used 
immediately  after  successful  restoration,  also  subpreputial  irrigations 
and  hand  injections.  Older  and  irreducible  cases  require  operative 
measures  after  a  local  anesthetic  of  cocain,  novocain,  stovain  or  their 
analogues  injected  into  the  midline  of  the  dorsum  above  and  through 
the  constricting  band,  and  after  sterilization  of  the  ulcer  with  tincture 
of  iodin,  the  band  is  divided,  layer  by  layer  with  a  scalpel  until  it  is 
fully  cut  through  and  the  tunica  albuginea  is  seen  at  the  depth  of  the 
wound.  Such  incision  is  usually  three-quarter  inch  long  and  permits 
immediate  restoration  of  the  parts,  followed  by  wet  dressing.  The 
dorsal  vein  of  the  penis  is  sometimes  cut  in  this  operation  and  will 
bleed  unduly  unless  ligated.  An  equally  good  technic  is  to  buttonhole 
the  skin  in  the  normal  zone  above  the  constricting  band  and  then  pass 
a  blunt  grooved  director  down  to  and  along  the  tunica  albuginea  and 
beneath  the  band  so  far  as  the  corona  glandis.  Upon  the  director  the 
band  is  then  cut  through  in  its  entire  thickness  and  breadth  with  one 
stroke  of  the  knife.  The  author  prefers  this  method  because  the 
director  isolates  and  retracts  the  band  away  from  the  body  of  the  organ. 
A  wet  dressing  is  again  the  immediate  aftertreatment,  which  is  con- 
tinued on  surgical  lines  until  the  little  wound  is  healed  and  the  remote 
aftertreatment  is  summed  up  in  the  toilet  of  the  foreskin  against 
return  of  the  paraphimosis  and  in  circumcision  as  permanent  relief  of 
the  underlying  and  resulting  deformity. 

Cure  requires  recovery  from  the  infection  and  gangrenous  ulcer 
without  any  or  much  deformity*.  Reparative  measures  against 
unsightly  flaps  complete  the  case. 


BALANITIS,  POSTHITIS  AND  BALANOPOSTHITIS. 

Defiiution. — The  glans  is  covered  with  and  the  foreskin  is  lined 
not  by  mucous  membrane,  as  formerly  supposed,  but  by  modified 
skin  which  is  capable  of  infection  and  inflammation,  When  the  glans 
alone  is  affected  the  lesion  is  known  as  balanitis,  and  when  the  foreskin 
is  chiefly  involved  the  term  posthitis  is  used,  and  finally  when  the 
inflammation  is  generalized  it  is  called  balanoposthitis. 

Varieties. — The  following  types  may  be  distinguished:  (1)  as  to  site, 
balanic  and  posthic  as  localized  and  balanoposthic  as  generalized; 
(2)  as  to  course,  acute,  subacute,  chronic  and  relapsing;  (3)  as  to 
foreskin,  retractible  and  irretractible ;  (4)  as  to  degree,  mild,  marked 
and  severe;  (5)  as  to  infection,  suppurative,  croupous  or  diphtheritic, 
syphilitic,  chancroidal,  gonococcal,  diabetic  and  herpetic.  Distinction 
as  to  the  course,  retractibility  of  the  foreskin  and  form  of  infection  is 


90       co^[PLICATInxs  axd  sequels  of  acute  urethritis 

iniportant.  aiul  this  work  is  c(»iicenie(l  with  the  gonococcal,  whicli  is 
taken  as  a  type. 

Etiology.- — Etiok^gy  is  predisposing  and  excitinu'.  'i'he  i)redisposmg 
cause  is  peculiarity  or  defect  of  the  foreskin  sunnned  up  in  ])hiniosis 
and  deficiency,  riiiniosis  with  its  lonji'  or  redundant,  straight  or 
angulated,  tight  or  flaccul,  small  or  strictured  outlet  and  deficient  or 
elongated  freniun,  imprisons  the  normal  smegma  in  its  folds,  stimulates 
its  decomposition  and  invites  infection  from  any  source,  so  that  in 
gonococcal  in^•asion  the  ]>us  from  the  urethra  easily  travels  into  the 
recesses  and  produces  characteristic  inllammation.  A  deficient  fore- 
skin may  by  exposure  to  irritation  also  predispose.  Traimia  in  causing 
loss  of  epithelium  is  an  important  predis])osing  cause,  such  as  arises 
during  excessive  coitus,  masturbation  and  the  friction  of  warts  within 
the  foreskin.  Intercourse  with  a  woman  having  too  small  genitals 
for  the  penis  of  the  man  acts  in  the  same  M'ay,  and  the  acridity  of 
leucorrhea  and  of  the  normal  vaginal  secretion  just  before,  during 
or  just  after  the  menses  may  also  prepare  the  modified  skin  for  infection. 
The  exciting  cause  is  therefore  penetration  of  any  organism  into  the 
fa^•orable  soil  tlnis  prei)ared,  or  in  virtue  of  the  decomposition  of 
smegma  the  change  of  organisms  normally  present,  from  innocuous  to 
nocuous  types,  occurs.  According  to  the  variety  of  organism  gaining 
access  the  t^pes  of  disease  are  recognized.  The  pyogenic  germs  evolve 
suppurative,  the  gonococcus,  gonococcal;  the  Treponema  jxtUidum, 
syphilitic;  the  bacillus  of  Ducrcy,  chancroidal;  and  the  decomposition 
and  infection  of  sugary  urine  diabetic  balanitis.  Herpes  progenitalis 
may  cause  active  lesions  in  the  same  manner  as  chancre  and  chancroid. 

Pathology. — All  ages  from  infancy  to  advanced  life  have  the  same 
essence  of  process,  which  is  infection  of  the  modified  skin  of  the  glans 
and  foreskin,  with  suppurative,  gonococcal,  sj'philitic,  chancroidal  and 
diabetic  inflammation.  The  temporary  lesions  are  the  commonest 
and  comprise  superficial  desquamation  or  erosion  and  ulceration  in 
accordance  with  the  activity  of  the  process.  In  the  suppurative  and 
gonococcal  lesions,  ulcers  are  relatively  uncommon,  but  are  the  nature 
of  the  chancre  in  sj^hilitic  and  of  the  soft  venereal  sore  in  chancroidal 
disease,  and  are  by  no  means  rare  as  gangrene  in  diabetes.  Permanent 
lesions  are  absent  except  as  the  scars  of  deep  erosions  in  the  violent 
suppurati^'e  and  gonococcal  cases  and  of  chancres,  chancroids  and 
gangrene.  The  associated  lesions  do  not  occur  in  suppurative  and 
gonococcal  balanoposthitis  unless  -extreme,  but  in  syphilis  the  systemic 
pathology  of  the  disease  may  be  already  present  or  soon  appear,  and 
in  chancroid  an  active  hinphatic  involvement  may  be  present  and  in 
diabetes  gangrene  of  the  foreskin.  The  complicating  lesions  are  usually 
h-mphangeitis  and  lymphadenitis.  These  may  be  absent  or  very 
marked.  In  suppuration  and  gonococcal  disease  of  the  foreskin  and 
glans  they  are  rare — if  marked,  then  a  mixed  or  associated  infection 
must  be  looked  for.  In  syphilis  the  vessels  are  cordlike  and  the  glans 
indurated,  discrete  and  movable  and  in  chancroid  the  vessels  are 
inflamed  and  tender  and  the  nodes  indurated,  matted  and  fixed  to  the 


BALANITIS,  POSTHITIS  AND  HALANOPOSTIIITIS  91 

skin  and  deeper  parts.  Abscess  of  the  glands  is  not  uncommon  in 
chancroid.  Diabetic  gangrene  may  have  much  the  same  complications. 
Herpetic  lesions  show  the  papular,  pustular  or  ulcerous  spots,  imJivifiu- 
ally  or  collectively,  with  tlie  other  signs  of  .balanitis  and  posthitis.  These 
lesions  are  all  mild  and  temporary.  According  to  the  tyi^e  of  disease, 
the  infecting  organisms  are  regularly:  the  normal  flora  of  the  foreskin 
(evolved  to  vicious  activity),  the  gonococcus,  the  Treponema  jjallidum, 
the  bacillvs  of  Ducrey  and  a  variety  of  organisms  in  decomposing  dia- 
betic subpreputial  deposits.  No  definite  organisms  are  identified  with 
herpes. 

Symptoms. — These  vary  with  the  degree  of  the  disease  and  not  mate- 
rially with  its  distribution  as  balanitis,  posthitis  or  balanoposthitis, 
and  are  purely  local  because  in  the  strict  sense  subjective  and  objective 
systemic  signs  are  absent.  Exceptions  to  this  rule  are  manifestations 
of  the  constitutional  disease  in  syphilitic  and  diabetic  patients  and  of 
active  general  absorption  in  chancroidal  and  gonococcal  infection. 
Symptoms  of  the  invasion,  establishment,  termination  and  complica- 
tions are  seen.  The  period  of  invasion  is  usually  very  mild  in  the  simple 
cases  and  masked  by  the  gonococcal  urethritis  in  this  form  of  balanitis. 
If  present  in  this  period  at  all  the  signs  are  extremely  mild  and  of  the 
same  kind  as  in  the  establishment  of  the  process.  The  local  subjective 
symptoms  in  gonococcal  balanitis  are  more  violent  than  in  the  simple 
suppurative  form,  but  the  former  is  the  more  common  and  directly 
in  our  interest.  The  chief  complaints  are  sensations  and  discharge. 
The  sensations  vary  among  itching,  pain,  burning,  feeling  of  foreign 
body  under  the  foreskin  and  desire  to  rub  or  pull  the  foreskin  about. 
These  sjTnptoms  are  known  by  the  intelligent  patient  not  to  be  in  the 
urethra,  because  they  continue  after  the  urethra  has  been  cleansed  by 
the  act  of  m-ination.  In  retractible  foreskin,  the  discharge  is  noticed 
only  from  the  folds  and  not  from  the  urethra,  and  in  irretractible  fore- 
skin it  appears  on  pressme  on  the  prepuce  rather  than  on  the  urethra, 
after  the  canal  is  freed  of  gonococcal  pus  by  urination.  If  erosions 
and  superficial  ulcers  are  present  the  patient  wall  often  seek  advice 
for  these  after  neglect  of  the  stage  of  discharge,  on  the  theory  that 
he  has  chancres  or  chancroids. 

The  local  objective  signs  are  determined  by  the  degree  of  the  attack, 
being  few  in  mild,  many  in  marked  and  many  and  severe  in  extreme 
cases. 

I.  Cases  ivith  Retractihle  Foreskins. — ^The  glans  alone  or  with  the 
foreskin  in  part  or  whole  is  red,  glistening  and  edematous  in  mild  cases 
and  early  stages  of  severe  forms.  ^Maceration,  desquamation  and 
erosion  in  spots,  large  areas  or  miiversally  mark  further  progress. 
Vesicles  and  pustules  are  frequent,  which  break  under  retraction  of 
the  foreskin  and  simple  cleansing  of  the  parts,  leaving  behind  erosions 
or  ulcerations  at  their  bases.  The  discharge  is  either  characteristic  of 
gonococcal  urethritis  or  modified  by  the  addition  of  the  balanitis  and 
foul  smegma.  It  is  milky  and  has  a  disagreeable  penetratmg  odor, 
regarded  as  diagnostic  of  the  simple  cases.    Gonococci  are  present  in 


92  CO^[PLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

the  (Iiscliarc:e  combined  with  the  organisms  of  sui)piiration,  catarrhal 
itiHanimation  ami  of  the  normal  flora  of  the  i)repiice.  The  discharge 
wells  up  from  the  folds  of  the  foreskin  and  especially  back  of  the 
corona.  Severe  types  are  the  extremes  of  the  disease  and  occur  in 
patients  with  ])oor  health  and  without  resistance  to  disease  and  in 
l)ersons  witli  uncleanliness  from  hal)it  or  occupation.  Tlcerations  may 
extend  like  ami  must  be  distinguished  from  chancroid  and  ncoi)lasm, 
and  the  lymphatics  may  be  involved  in  acute  inflammation  of  ^-essels 
and  glands  and  even  inguinal  abscess. 

II.  Cdfieft  with  IrreirariihJe  Fnrcshin. — Inspection  of  the  jiart  is 
possible  only  with  urethral  specula,  of  which  none  is  more  convenient 
than  the  Skcne-Folsom,  short  Chetwood  or  Buerger.  The  outlet  of 
the  foreskin  is  dilated  with  the  blades  of  the  Skene-Folsom  speculum 
and  its  cavity  illuminated  with  a  lam])  and  head  mirror  or  a  urethro- 
scopic  lam})  and  the  i)us  carefully  wi])ed  from  the  urinary  meatus. 
Pressure  on  the  foreskin  then  brings  into  the  field  \()lumes  of  pus 
which  do  not  come  from  the  urethra.  The  Chetwood  or  the  Buerger 
urethroscope  may  now  be  inserted  to  the  corona  for  determination  of 
the  other  conditions  described.  In  both  forms  of  the  disease,  ])alpation 
of  the  foreskin  and  glans  is  usually  very  painful,  in(lei)endently  of  the 
urethral  inflammation,  of  Avhich  the  balanoposthitis  is  a  complication. 
When  these  special  instruments  are  not  at  hand  the  following  procedure 
serves:  A  pledget  of  cotton  may  be  inserted  into  the  meatus  in  order 
to  retain  the  gonococcal  pus  of  the  urethritis,  after  having  cleansed 
the  tip  of  the  glans,  as  seen  through  the  opening  of  the  foreskin,  (lentle 
pressure  upon  the  penis  back  of  its  head  and  away  from  the  urethra 
will  always  bring  away  pus  into  the  field,  which  obviously  cannot 
come  from  the  urethra  on  account  of  the  plug  of  cotton  which  is  then 
removed. 

The  stage  of  termination  in  gonococcal  balanitis  is  not  as  well  marked 
as  in  the  simpler  forms,  because  masked  in  exactly  the  same  way  as  the 
invasion.  It  may  be  said,  however,  the  subjective  symptoms  decline 
and  sensations  of  the  balanoposthitis  slowly  merge  into  those  of  the 
persisthig  urethritis  if  this  is  acute,  but  if  chronic  then  the  distinction 
between  the  two  processes  is  marked.  The  objective  symptoms  also 
disappear.  The  discharge  lessens  and  rapidly  ceases  under  cleanliness, 
dresshig,  drainage  and  treatment,  so  that  again  only  the  gonococcal 
discharge  from  the  urethra  is  present.  Erosions,  desquamation  and 
maceration  of  epithelium  soon  heal,  leaving  normal  modified  skin. 
Ulcers  heal  more  slowly  and  leave  scars  of  various  number,  size  and 
depth  behind.  If  severe  complications  have  been  present  in  lymph 
vessels  and  glands  these  will  heal  slowly  also.  Full  reccnery  is  the  rule 
without  permanent  damage  in  the  gonococcal  and  sui)])urative  types. 
But  in  the  ulcerating  lesions,  such  as  chancroid  and  chancre,  and  in 
diabetes,  destruction  of  glans  and  foreskin  may  be  extensive. 

The  symptoms  of  the  course  and  terminaticm  of  the  other  forms  of 
balanitis  have  l)een  sufficiently  discussed  under  the  subjects  of  ])himoses 
of  the  same  varieties — namely,  s}i)hilitic,  chancroidal,  diphtheritic 
and  diabetic. 


BALANITIS,  POSTHITIS  AND  BALANOPOSTIIITIS  93 

Complications. — Complications  of  gonococcal  balanitis  occur  less 
frequently  tlian  with  the  ulcerating  forms  and  are  of  the  same  types 
as  follow:  Phimosis  and  paraphimosis  are  not  only  causes  hut  also 
complications  or  sequels  of  balanitis,  and  a  careful  history  of  the  case 
alone  distinguishes  the  onset.  Lymphangitis  is  usually  indolent  and 
cordlike,  but  may  be  active  and  tender,  and  lymphadenitis  may  like- 
wise be  subacute  and  scarcely  painful  or  acute  active  and  painful, 
with  outcome  in  abscess.  Cellulitis  of  the  skin  sheath  of  the  penis  in 
whole  or  part  as  a  universal  or  localized  inflammation  may  follow  the 
lymphatic  involvement  or  occur  more  or  less  without  it.  The  gono- 
coccal urethral  lesions  from  which  the  balanitis  proceeded  are  associated 
rather  than  complicating  lesions.  Gangrene  arises  in  diabetic  balanitis 
and  is  worthy  of  separate  note.  On  this  point  Taylor^  says:  "Not 
infrequently,  particularly  in  uncleanly  persons,  in  diabetics,  also  in 
those  debilitated  by  disease  or  excesses,  gangrene  of  the  prepuce  occurs 
from  balanitis.  Owing  to  the  inflammation  of  the  parts  and  the 
swelling  of  the  glans,  a  black  spot  forms  about  the  middle  of  the  prepuce 
and  through  the  buttonholelike  opening  which  results,  the  glans 
protrudes." 

That  which  is  said  concerning  the  lymphatic  system  of  the  penis 
in  the  following  paragraphs  under  the  subject  of  lymphangitis  and 
lymphadenitis  applies  to  all  these  foregoing  conditions  and  these 
anatomical  facts  should  always  be  borne  in  mind. 

Diagnosis. — Balanitis,  posthitis  and  balanoposthitis  are  lesions  diflFer- 
ing  from  each  other  simply  in  distribution  as  noted  in  the  definition 
of  the  acute  and  chronic  forms  in  their  appropriate  sections  on  pages 
89^97.  Balanitis  is  limited  to  the  glans  penis,  posthitis  to  the  lining 
of  the  foreskin  and  balanoposthitis  to  both  regions  combined.  Dis- 
tinction between  the  acute  and  the  chronic  form  is  one  of  activity  of 
pjrocess  and  history,  because  the  diagnostic  procedures  are  the  same 
for  each. 

The  history  acknowledges  any  or  several  of  the  following  causal 
elements:  Phimosis,  paraphimosis,  excessive  or  unnatural  inter- 
course or  union  with  a  woman  having  undeveloped  external  sexual 
organs,  acute  or  chronic  urethritis  especially  with  relapses,  and  indo- 
lent sore  suggesting  syphilis  or  a  more  active  ulcer  indicatmg  chan- 
croid, warts  with  their  irritation  and  discharge,  and  perhaps  pruritus 
of  the  genitals  common  with  diabetes.  The  subjective  symptoms 
concern  the  degrees  of  itching,  burning  and  discharge,  primary  or 
secondary  to  any  of  the  foregoing  causes  and,  especially  for  our  pur- 
poses, to  acute  and  chronic  gonococcal  infection  or  otherwise  conse- 
quent upon  sores,  warts  and  sugar  in  the  urine.  Presence  of  the 
gonococcus  may  be  an  intercurrent  factor  and  not  either  exciting  or 
complicating  the  lesion.  The  objective  signs  determine  the  source 
and  bacteriology  of  the  discharge  and  its  effect  on  the  cavity  of  the 
foreskin  and  settles  the  relation  of  possible  etiologic  data  as  just 

1  Loc.  cit.,  p.  246. 


94  COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

stated.  The  treatment  of  the  case  is  of  vahie  in  setting  apart  from 
each  other  the  various  recognized  forms,  most  especially  the  s>'philitic, 
chancroidal,  true  diphtheritic  and  diabetic. 

Differential  Diagnosis. — The  diiVcrential  diagnosis  contains  the  history 
of  anlor,  pain  antl  tenderness  only  about  the  foreskin  and  glans  and 
not  within  the  urethra  and  in  showing  only  the  first  glass  of  urine 
slightly  turbid.  Posthoscopy  shows  the  cavity  of  the  foreskin  alone 
to  be  involved  and  the  urethra  to  be  normal. 

Differential  diagnosis  of  the  varieties  of  Ixilanitis  from  our  chief  sub- 
ject, gonococcal  manifestations,  must  include  suppurative,  diphtheritic, 
syphilitic,  chancroidal,  diabetic,  papillomatous  and  cancerous  disease. 

Siippurniirc  differs  from  gonococcal  baJcmifis  iu  its  history  of  frequent, 
often  unexplaincnl  attacks  or  otherwise  origin  from  sunple  causes; 
in  its  freedom  from  the  gonococcus  and  abundance  of  catarrhal  or  sup- 
purative organisms;  in  its  subjective  symptoms  often  mild,  simple  and 
brief  and  independent  of  urethritis  or  its  complications  and  sequels; 
in  its  objective  signs  of  chiefly  redness  and  edema,  rarely  excoriations, 
and  of  pus  from  the  folds  of  the  foreskin  and  not  from  the  urethra; 
in  its  prompt  and  complete  response  to  simple  cleanliness,  antisepsis, 
stimulation  and  dressing;  and  finally  in  its  termination  in  full  recovery 
as  the  rule  with  rare  exceptions  and  without  persistence  of  urethral 
lesions  thereafter. 

Diphtheritic  or  croupous  diff'ers  from  gonococcal  balanitis  through  its 
record  of  no  gonococcal  disease  but  of  infection  of  a  wound  or  opera- 
tion on  the  foreskin  or  of  involvement  during  acute  systemic  disease 
or  its  prolonged  convalescence,  such  as  scarlet  fever,  measles,  small- 
pox, diphtheria,  typhoid  and  the  like;  in  its  subjective  symptoms  of 
severe  reaction  to  operation  and  intense  involvement  of  the  cavity 
of  the  foreskin  showing  severe  pain,  bleeding  and  discharge  and  in  its 
objective  signs  such  as  scales  and  flakes  of  false  membrane  w^hich  are 
shed  from  the  surface  of  the  glans  and  lining  of  the  foreskin  with 
absence  of  the  gonococcus  but  presence  of  the  bacillus  of  diphtheria 
or  other  organisms;  in  its  response  to  antidiphtheritic  sermn  as  treat- 
ment and  to  other  active  antiseptic  measures  and  finally  in  its  termina- 
tion without  the  persistence  of  urethral  lesions  of  gonococcal  nature 
and  at  times  with  the  sequels  of  diphtheritic  infection.  In  typical 
cases  the  membrane  is  the  duplicate  of  that  seen  in  diphtheria  of  the 
throat,  grayish- white  or  reddish-white  in  color,  leaving  ulcers  behind 
and  haA'ing  tendency  to  early  involvement  of  the  inguinal  glands 
exactly  as  the  cervical  glands  are  comprised  in  lesions  of  the  throat. 

Syphilitic  diff'ers  from  gonococcal  balanitis  in  its  acknowledgment  of 
slow  invasion  in  the  third  to  the  sixth  week  of  chancrous  and  the 
sixth  to  the  twelfth  week  of  macular  and  papular  lesions  of  the  second 
stage;  in  its  subjective  symptoms  of  comparative  painlessness  and 
unimportance  until  the  discharge  appears  as  chief  complaint;  in  its 
objective  findings  of  no  gonococci,  of  a  chancre  or  papule  seen  under  or 
felt  through  the  foreskin  with  the  Treponema  pallidum;  in  the  foul- 
smelling  serous  or  serosanguineous  discharge  and  tissue  and  of  other 


BALANITIS,  POSTHITIS  AND  BALANOPOSTHITIS  95 

signs  of  syphilis,  such  as  characteristic  lymph  vessels  and  glands, 
generalized  rash  of  the  skin  and  moist  papules  of  the  mucosae  and 
positive  Wassermann  test;  in  its  prompt  response  to  local  and  sys- 
temic antisyphilitic  measures  of  treatment  and  finally  in  its  termina- 
tion at  the  same  time  as  the  other  signs  of  syphilis,  if  present,  or  mer- 
gence with  them  at  their  appearance  as  part  of  the  general  syphilitic 
process.  Balanitis  may  appear  in  the  stage  of  erythema  in  the  very 
early  secondary  period  or  in  the  gumma  of  the  tertiary  period.  Mani- 
festly retractible  foreskins  permit  a  prompt  and  accurate  diagnosis 
while  irretractible  ones  limit  examination  to  palpation  and  inspection 
through  a  speculum. 

The  varieties  of  a  chancre  described  by  Taylor^  must  not  be  for- 
gotten: Chancrous  erosion,  silvery  spot,  dry  papule  or  patch,  umbili- 
cated  papule  or  nodule,  purple  necrotic  nodule  and  ecthymatous 
chancre  as  typical  forms,  and  ulcus  elevatum,  multiple  herpetiform 
chancre,  parchment  chancre,  annular  chancre,  indurated  nodule  or 
mass,  chancre  with  cream-green  membrane  and  infecting  balano- 
posthitis  as  atypical  forms.  As  a  source  of  error  the  infecting  balano- 
posthitis  is  highly  important  but  usually  shows  at  one  or  more  points 
diagnostic  infiltrations  of  syphilis.  A  section,  however,  of  every  sus- 
pected lesion  must  be  sent  to  a  pathologist. 

Chancroidal  differs  from  gonococcal  balanoposthitis  in  soon  after 
intercourse  giving  a  history  of  active  ulcer,  neglected  until  pain  and 
discharge  appear;  in  its  subjective  symptoms  of  pain,  bleeding,  acute 
discharge  and  early  involvement  of  the  inguinal  glands,  with,  on 
objective  examination  of  the  retracted  foreskin,  a  characteristic  soft 
venereal  ulcer,  containing  the  bacillus  of  Ducrey  and  without  urethri- 
tis unless  the  chancroid  is  at  the  meatus,  and  then  without  gonococci 
and  with  early  acute  tender  involvement  of  the  inguinal  glands  and 
penile  vessels;  in  its  rather  slow  response  to  treatment  with  tendency 
to  extension  and  autoinoculation  even  during  applications  and  finally 
in  its  termination  in  excavated  deforming  scars  of  glans  and  foreskin 
and  not  uncommonly  in  abscesses  of  the  groins.  As  stated  in  the 
previous  paragraph  on  syphilitic  balanitis,  cases  with  retractibility 
of  the  foreskin  permit  immediate  diagnosis  while  those  with  irretract- 
ible phimosis  render  the  process  much  -more  difficult.  In  the  late 
untreated  cases  signs  of  pus  in  the  lymph  glands  of  the  groins  are 
important — namely,  redness,  glossiness,  edema,  fixation  of  the  skin, 
swelling,  tenderness  and  tension  or  fluctuation  of  the  glands. 

Diabetic  differs  from  gonococcal  posthitis  and  balanitis  in  its  knowl- 
edge of  sugar  in  the  urine  with  absence  of  gonococcal  or  other  urethral 
lesion,  except  at  times  diabetic  urethritis;  in  its  subjective  symptoms 
of  severe  itching  like  the  pruritus  of  the  genitals  and  anus  which  often 
precede  it  with  sometimes  glycosuric  uretliritis;  in  its  objective  signs  of 
acetone  breath,  sugar  in  the  lu-ine,  lividity,  excoriation  and  exfolia- 
tion of  the  epithelium  in  the  discharge  which  contains  decomposing 

^  Genito-urinary  and  Venereal  Diseases,  3d  ed.,  p.  500. 


9(>  COyfPlJCATIOXS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

sine<];ma  and  niicrooriranisms.  witli  toiulency  to  ulcer,  j>;angrene  and 
verruca;  in  its  benefit  throuiih  relief  of  sugar  in  the  urine  and  local 
cleanliness  and  finallx'  in  its  termination  in  recovery  or  a  severe  gan- 
grenous sequel  or  in  its  relapses  with  every  return  of  sugar  in  the  urine. 
In  doubtful  cases,  having  no  sugar  in  the  urine,  hematological  exami- 
nation will  reveal  its  accumulation  in  the  blood  where  sugar  is  patho- 
logicall\'  present  before  it  appears  and  after  it  disappears  from  the  urine. 

PaplHoniatous  or  warty  differs  from  gonococcal  bah  no  posthitis  in  the 
notice  by  the  patient  of  warts  ]ircceding  the  condition,  of  almost  total 
absence  of  pain  and  inflainmation.  Objectively  the  condition  is 
purely  a  mechanical  irritation  of  the  parts  into  a  catarrhal  inflamma- 
tion. Retraction  of  the  foreskin  at  once  reveals  the  diagnosis,  as  will 
posthoscopx'.  Edema  is  usually  absent  unless  the  inflammatory 
change  has  been  profound.  The  discharge  is  mucoserous  or  mucopuru- 
lent and  contains  no  organisms  of  syphilitic,  chancroidal  or  gonococcal 
infection  unless  in  the  last  instance  the  papillomata  complicate  a 
chronic  urethral  lesion. 

Cancerous  differs  from  gonococcal  haJanoposthitis  in  that  it  is  pre- 
ceded liy  the  typical  induration  and  ulceration  of  epithelioma  and 
followed  by  the  usual  infiltration  and  fixation  of  the  mass  and  the 
lymph  vessels  and  lymph  glands  in  relation  to  it.  Inflammation  is 
relatively  little  excepting  in  the  ulcer  itself.  The  discharge  is  sanious, 
fertile  in  the  products  of  the  ulcer  but  barren  in  the  special  organisms 
already  mentioned.     A  section  is  the  final  diagnostic  aid. 

Cardiovascular  differs  from  gonococcal  balanopost Iritis  in  that  it  is 
secondary  to  disease  of  the  heart,  vessels  and  kidneys,  being  accom- 
panied by  pronounced  edema  of  the  lower  extremities  and  sexual 
organs,  which  produces  a  manifest  phimosis.  Extreme  cases  of  this 
condition  are  at  times  seen.  Inflammation  of  the  foreskin  is  relatively 
little  in  most  cases.  The  discharge  would  necessarily  be  mucus, 
serum  or  mucoseruin  and  devoid  of  any  infectious  organisms.  Exami- 
nation of  the  heart,  bloodvessels,  liver,  lungs,  kidneys  and  urine 
immediately  clears  the  diagnosis  (Fig.  17). 

Chronic  Balanitis,  Posthitis  and  Balanoposthitis  are  invohed  like 
phimosis  with  frequent  attacks  of  any  of  the  foregoing  forms  and 
their  causes  until  at  last  a  persistent  or  a  relapsing  inflammation  is 
established.  The  symptoms  are  those  of  infiltration,  excoriation, 
fissure  and  discharge.  The  features  of  the  various  forms  just  described 
need  not  be  repeated.  When  the  foreskin  is  irreducible  examination 
with  the  meatoscope  or  the  urethroscope  reveals  these  lesions. 

Treatment  of  Gonococcal  Acute  and  Chronic  Balanitis,  Posthitis  and 
Balanoposthitis. — These  lesions  are  in  their  significance  commonly 
minor,  rarely  major.  Prevention  and  abortion  rely  on  the  treatment 
of  phimosis  and  allied  conditions,  which  in  both  the  congenital  and 
acquired  forms  are  very  apt  to  have  a  balanoposthitis — acute  or  chronic 
with  relapses  or  chronic  with  persistence  and  progress  of  symptoms. 
As  the  best  preventive,  circumcision  is  indicated  whenever  there  has 
been  an  acute  nongonococcal  attack  or  chronic  lesions. 


PREPUTIAL  FOLLICULITIS  97 

Curative  Treatment. — Relief  of  these  complications  must  be  deter- 
mined by  the  indications. 

Curative  treatment  develops  in  accordance  with  the  acute  or  chronic 
symptoms  of  itching,  i)ain,  ardor  urinse,  rubbing  of  the  foreskin  and 
discharge  free  at  the  opening  in  irretractible  cases  or  held  within  the 
folds  of  retractible  foreskins  associated  with  excoriations  and  ulcera- 
tions. Antisepsis  of  the  discharge,  rest  in  bed  with  the  penis  sup- 
ported, diluents  and  antacids  in  drink  and  food  are  the  management 
and  hot  irrigations,  hot  penile  baths  and  sitting  baths  against  the 
edema  and  discharge  are  the  hydrotherapy.  In  retractible  cases 
medicinal  measures  are  hot  antiseptic  and  astringent  penile  baths 
for  twenty  minutes  twice  a  day,  preferably  of  potassium  permanga- 
nate 1  in  4000  to  1  in  1000,  aided  by  hand  injections  of  the  same  every 
two  hours  with  the  long  rubber  tip  subpreputial  syringe.  Painting  or 
washing  the  glans  and  foreskin  with  nitrate  of  silver,  1  in  2.50  to  1  in  125, 
is  almost  magic  especially  for  the  ulcers  and  excoriations.  Drying 
and  antiseptic  powders  and  the  standard  penile  dressing  (Figs.  10  and 
11)  are  the  last  step.  In  chronic  cases  the  applications  are  usually 
somewhat  stronger.  In  irretractible  cases  the  only  means  are  irriga- 
tion of  the  foreskin  by  the  author's  method  and  hand  injection.  When 
retraction  is  again  possible  return  to  the  other  methods  is  indicated. 

Relapse  is  prevented  by  the  toilet  of  the  foreskin  during  the 
urethritis. 

Author's  Subpreputial  Irrigation. — This  means  of  treatment  requires 
a  reservoir,  tubing,  the  Valentine  or  other  cut-off  and  shield,  a  female 
catheter  with  a  hub  fitting  the  shield,  both  as  shown  in  Fig.  18,  as 
equipment.  The  patient  is  prepared  with  the  standard  draping  (Fig. 
15)  reclining  on  the  operating  table  or  standing  exposed  as  in  Fig.  1.3 
before  a  sink  or  other  office  fixture.  The  technic  passes  the  catheter 
under  the  foreskin  while  gauze  is  dropped  over  penis  and  catheter 
to  catch  all  splash  and  lead  it  into  the  Wolbarst  basin  between  the 
thighs.  The  flow  is  opened  at  high  head  of  pressure  to  balloon  out  the 
foreskin  and  about  one  gallon  of  irrigation  is  used,  of  1  in  4000  to  1 
in  1000  hot  potassium  permanganate  solution,  twice  a  day. 

Cure  requires  relief  of  the  infection  without  preputial  folliculitis  or 
other  complication  and  without  tendency  to  chronicity.  Aftertreat- 
ment  is  circumcision  which  ciu-es  the  underlying  congenital  deformity 
and  the  natural  tenderness  of  the  parts  seen  in  phimotic  subjects. 
The  operation  is  usually  done  after  all  gonococcal  disease  is  absent  and 
especially  if  the  thickenings  of  chronic  phimosis  are  present. 

PREPUTIAL  FOLLICULITIS. 

Definition.- — This  acute  complication  may  be  described  as  gono- 
coccal infection  of  the  follicles  of  the  prepuce,  which  are  really  glands 
with  ducts  much  like  those  within  the  urethra  itself  and  for  the  most 
part  evacuating  at  or  near  the  margin  of  the  foreskin  where  the  true 
and  modified  skin  meet. 
7 


98  COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

Varieties. — Acute,  subacute  and  chronic  arc  the  chnical  types,  of 
which  the  last  is  discussed  later.  Cases  without  abscess  and  with 
abscess  of  the  foreskin  itself  and  abscess  of  the  follicles  near  the  fre- 
num  are  forms  as  to  severity.  Such  abscesses  are  rather  minute, 
though  unmistakable  and  are  not  to  be  confused  with  periurethral 
abscesses  of  large  jiroportions  and  described  under  their  own  heading. 

Etiology .^A  long,  tight  foreskin  is  the  predisposing  local  cause,  with 
a  tendency  to  frequent  attacks  of  sbnple  balanoposthitis  through 
retention  and  decomposition  of  smegma.  This  condition  results  in 
relaxation  and  patency  of  the  ducts  and  invites  the  penetration  of  the 
gonococcus  as  the  exciting  cause  during  the  balanoposthitis  which 
always  occurs  in  such  a  foreskin. 

Pathology. — As  in  all  other  gonococcal  invasion  the  essence  of  the 
process  is  penetration  of  the  organism  along  the  duct  and  into  the 
gland  followed  by  exfoliation,  proliferation  of  the  lining,  pus  forma- 
tion containing  gonococci,  modified  secretion  and  detritus.  The 
temporary  lesions  are  these  and  seen  only  in  mild  cases  of  true  follicu- 
litis without  abscess,  but  the  permanent  lesions  are  destruction  of 
the  gland  by  the  abscess,  which  leaves  chronic  sinus  or  even  urethro- 
preputial  fistula. 

Symptoms. — So  slight  a  lesion  has  no  invasion  distinguishable  from 
the  gonococcal  acute  urethritis  which  it  complicates.  In  fact,  in 
irretractible  foreskins  it  is  often  not  recognized  until  the  declining 
stage  reveals  the  sinus  or  fistula.  In  a  retractible  foreskin,  the  sub- 
jective establishment  is  manifested  by  discomfort,  pain  and  discharge, 
or  by  relapses  of  balanoposthitis  bringing  the  folliculitis  to  the  front. 
Objective  signs  are  redness,  edema  and  enlargement  of  the  gland  and 
its  duct  froQi  which  pus  containing  gonococci  dribbles  or  may  be 
expressed.  The  refined  sensitiveness  of  minute  abscess  is  always 
present.  The  termination  is  commonly  by  spontaneous  external 
evacuation  if  no  abscess  occurs,  or  rupture  upon  the  surface  of  the 
foreskin  or  near  the  frenum  or  Aery  rarely  into  the  urethra.  Com- 
plete healing  may  then  occur  or  a  chronic  infiltration,  sinus  or  fistula 
result.  The  clinical  significance  of  these  little  lesions  is  that  they  may 
be  the  carriers  of  infection  into  wedlock  or  even  of  autoinfection  under 
a  simple  exciting  cause. 

Diagnosis. — In  the  history  of  acute  preputial  folliculitis  during  a 
gonococcal  m-ethritis  the  follicles  of  the  prepuce  are  invaded  and  little 
abscesses  appear,  with  their  characteristic  symptoms  of  pain,  redness, 
swelling  and  finally  evacuation.  The  pus  may  be  expressed  in  little 
plugs  without  or  with  incision  of  the  abscess  and  a  small  pocket  remains. 

Chronic  Preputial  Folliculitis  shows  numerous  acute  attacks  in  its 
history  with  the  result  of  a  persistent  focus  or  pocket  which  is  always 
open  and  relapsing  and  has  the  symptoms  of  a  chronic  discharge, 
sinus  and  node  of  unhealed  abscess  if  there  is  no  occlusion  of  the  sinus, 
but  if  its  outlet  becomes  stopped  then  an  acute  folliculitis  with  all  the 
foregoing  features  originates.  The  laboratory  is  interested  in  smears 
and  culture  taken  from  these  abscesses  and  in  the  free  pus  of  the  fore- 


PARAURETHRAL  FOLLKJULiriS  99 

skin  for  the  gonococcus.  Treatment  of  the  urethritis  may  aid  in  tfie 
disappearance  of  this  compHcation  especially  if  attcr)tion  to  tin;  cavity 
of  the  foreskin  is  given  before  true  abscesses  appear.  Otherwioc  minor 
surgical  attention  settles  the  diagnosis. 

PARAURETHRAL  FOLLICULITIS. 

Defmition.^ — Paraurethral  or  juxtameatal  folliculitis  is  a  complica- 
ting gonococcal  condition  recognized  as  infection  of  the  little  glands 
at  or  near  the  meatus  leading  to  suppuration,  abscess,  sinus  or  fistula, 
lying  along  the  urethra  and  evacuating  in  or  near  the  hp  of  the  meatus 
on  the  surface  of  the  glans  and  not  on  the  lining  of  the  urethra. 


Fig.  19. — Gonococcal  paraurethral  folliciilitis  with  abscess.      The  abscess  has  not  yet 
ruptured  and  obstructs  the  meatus.    No  sinus  is  therefore  apparent.     (Taylor.*) 

Varieties. — Acute,  subacute  and  chronic  are  the  clinical  lesions  while 
unilateral  and  bilateral  as  to  situs  and  large  and  small  as  to  extent  are 
recognized,  as  well  as  cases  without  and  with  abscess. 

Etiology. — The  causes  of  paraurethral  folliculitis  duplicate  those  of 
the  preputial  follicles  and  need  no  further  discussion. 

Pathology. — Unusually  large  follicles  situated  along  the  margin  of  the 
meatus  emptying  upon  the  glans  are  the  basis  of  the  process  while 
infection  with  the  gonococcus  followed  by  the  usual  processes  excited 
by  it  is  the  essence  of  the  disease.  The  ducts  open  laterally  upon  one 
lip  in  unilateral  cases,  both  lips  in  bilateral  forms  and  at  either  upper 
and.  lower  commissure  in  mesial  cases,  almost  always  externally  but 
occasionally  externally  and  internally,  thus  forming  balanourethral 
fistulse.  The  length  of  such  passages  is  from  1  to  2  cm.  Temporary 
lesions  are  seen  only  when  there  is  no  abscess,  ^\hile  permanent  lesions 
with  destruction  of  the  follicle,  slight  stricture  of  the  meatus,  chi'onic 
sinus  and  fistula  are  common.  The  associated  lesions  are  regularly 
those  of  the  gonococcal  acute  uretliritis  wdiich  they  complicate. 

1  Loc.  cit. 


100        COMPLICATJOXS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

Sjnnptoms. — In  so  niimito  a  IosIdii  tluMV  is  commonly  no  discernible 
perioil  of  invasion,  the  i)atients  complaining  only  of  the  snbjective 
establishment  of  the  abscess  or  of  a  discharge  from  a  particular  point 
of  the  meatus,  lateral  or  central,  during  the  declining  period  of  the 
gonococcal,  infection  or  only  of  the  persistent  crusting  later  on.  The 
objccti\e  signs  are  a  red.  swollen  edematous  li[)  in  recent  cases  or 
normal  in  old  lesions  "with  patulous  duct,  "pinhole"  to  the  naked  eye 
or  magnifying  glass,  discharging  pus  spontaneously  or  permitting  its 
expression.  A  ])robe  will  enter  1  or  2  cm.  into  a  blind  sinus  or  a  balano- 
urcthral  fistula.  Crust  o^•er  the  meatus  when  removed  will  reveal 
these  conditions  which  are  the  sole  origin  of  the  crust  in  many  cases,  as 
distinguished  from  urethritis.  The  termination  is  in  mild  cases  recovery. 
Glands  with  short,  simple  ducts  also  tend  toward  recovery  or  a  chronic 
discharge  without  abscess.  Those  with  long,  tortuous  ducts  more  often 
have  abscess,  frequent  relai)ses  with  exacerbations  followed  by  sinus  or 
fistula.  The  clinical  imi)ortance  of  these  lesions  is  that  without  dis- 
comfort they  may  persist  for  years  and  become  the  source  of  infection 
in  marriage  or  of  autoinfection  through  some  slight  cause.  Hence, 
the  little  droj)  of  pus  within  them  should  always  be  examined  for  the 
gonococcus. 

Diagnosis. — Added  to  the  history  in  acute  paraurethral  folliculitis 
of  a  se\'ere  m-ethritis  is  that  of  a  ra]:»idly  developing  swelling  exactly 
at  the  meatus  on  one  or  both  sides  with  the  symptoms  at  first  of  pain, 
edema  and  obstruction  and  then  discharge  of  a  drop  of  pus,  frequently 
recm-rent.  Expression  of  the  pus  from  the  small  abscess  cavity  is 
usually  easy  with  the  fingers  alone,  but  frequently  this  method  develops 
pus  from  the  urethra  also. 

Chronic  Paraurethral  Folliculitis  shows  an  origin  in  acute  compli- 
cated attacks  in  its  history  or  several  attacks  of  urethritis  resulting  in 
the  abscess  and  then  the  chronic  sinus  with  a  mass  of  infiltration  tissue 
about  it  and  with  the  symptoms  of  pain  and  discharge  like  an  acute 
abscess  when  the  ojiening  closes  or  of  chronic  droj)  if  it  remains  open. 
The  prol>e  and  the  meatoscope  com})lete  the  diagnosis.  A  hairpin  or 
other  loop  may  be  passed  into  the  urethra  beyond  the  abscess  and  used 
to  express  its  contents  absolutely  for  laboratory  demonstration  of  the 
gonococcus  in  smear  and  culture.  Under  treatment  as  the  urethritis 
subsides  the  drop  of  ])us  from  the  follicle  ])ersists  aufl  does  not  cease 
imtil  local  applications  or  incision  and  drainage  oliliterate  the  pocket 
and  complete  the  diagnosis. 

Treatment  of  Gonococcal  Acute  and  Chronic  Preputial  and  Para- 
urethral Folliculitis.  Almost  in^'ariably  minor  and  not  major  im])or- 
tance  attaches  to  these  lesions.  Pre^■ention  is  only  the  toilet  of  the 
foreskin  in  irrigations,  powders,  baths  and  the  like  from  the  onset  of 
the  urethritis  and  the  only  abortive  means  are  hot  antiseptic  local 
applications  at  the  first  sign  of  folliculitis  but  are  usually  of  no  avail. 
\^  Curative  ircatiucnt  is  much  alike  in  both  these  lesions  which  differ 
only  as  to  their  sites  respectively  in  the  foreskin  and  the  meatus  and  is 
sjTiiptomatic  according  as  the  abscess  is  acute  and  blind  or  is  evacuated 


PERI  U  RET  JIB.  A  L  FOLLIC IJLA  R  A  liSC'ESS  ]  01 

or  chronic  with  i)ockct  or  sinus  causing  j)ain,  (h'sc(jrnfort,  enhirg(;rncnt, 
perforation,  discharge,  pocket,  sinus  aurl  associated  balanop(jsthitis. 

Electrotherapy  in  the  form  of  the  high-frequency  current  of  Oudin 
is  valuable  when  the  wire  may  })e  readily  introduced  into  the  follidf. 
The  spark  gap  should  be  one-eighth  inch  or  less  and  the  switch  half 
open.  The  current  should  blanch  and  not  char  in  a  few  seconds  and 
the  electrode  should  not  bring  away  tissue  with  it.  The  medicinal 
measures  are  chiefly  against  the  balanoposthitis  as  prescribed.  Incision, 
evacuation  and  sterilization  of  recent  cases  is  the  best  surgical  treat- 
ment, while  old  cases  may  require  curetting  and  stimulation,  occasion- 
ally ablation. 

Aftertreatment  provides  against  relapse  or  recurrence  by  proper 
attention  to  the  balanoposthitis. 

Cure  requires  healing  of  the  abscess  cavity  so  as  not  to  become  a 
source  of  chronic  infectiousness. 

PERIURETHRAL  FOLLICULAR  ABSCESS. 

Definition. — To  abscesses  of  variable  but  rather  large  size,  situated 
along  the  urethra  from  glans  to  penoscrotal  angle,  the  term  peri- 
urethral is  applied  and  should  distinguish  them  from  the  much  smaller 
and  less  significant  abscesses  in  small  follicles  near  the  freniun  just 
dismissed  as  preputial  folliculitis. 

Varieties. — Forms  are  distinguished  as  to  situs,  frenal,  penile  and 
penoscrotal,  unilateral,  bilateral  and  discrete,  bilateral  and  confluent 
and  finally  bilateral  by  extension  and  as  to  severity  without  and  with 
sinus  and  fistula  formation.  Bilateral  abscesses  may  arise  individually 
on  either  side  of  the  frenum  T\"hich  is  the  commonest  seat  and  remain 
discrete  or  become  confluent  into  a  common  cavity  or  after  arising  on 
one  side  may  erode  into  the  other  and  thus  simulate  the  former  kind. 

Etiology. — A  long,  tight  foreskin  with  tendency  to  sodden  mucosa, 
to  frequent  simple  balanoposthitis,  to  decomposition  of  smegma,  and 
to  relaxation  of  all  ducts  is  the  predisposing  cause  and  the  penetration 
of  the  gonococcus  is  the  exciting  cause,  so  far  as  the  frenal  tjq^e  is  con- 
cerned. The  penile  and  penoscrotal  types  arise  from  similar  infection 
of  the  larger  urethral  follicles.  They  are  regularly  associated  with  any 
period  of  severe  gonococcal  urethritis,  that  is,  the  full  establishment, 
decline  or  termination,  and  during  ckronic  urethritis,  as  subsequently 
discussed,  they  are  by  no  means  uncommon  under  any  additional  excit- 
ing factor. 

Pathology. — Tj'pical  gonococcal  abscess  formation  follows  occlusion 
of  the  duct  of  the  follicle  about  the  frenimi  or  within  the  urethra  w"ith 
probably  unilateral  frenal  situation  the  most  common.  The  other 
situations  are  spoken  of  under  ^'arieties.  The  essence  of  the  process  is 
invasion  of  the  gland  and  duct,  exfoliation,  penetration  of  the  organism, 
infiltration,  pus  and  detritus,  occlusion  of  the  duct,  destruction  of  the 
gland  and  finally  involvement  of  its  amiexa  in  extensive  abscess. 
Manifestly  temporary  lesions  are  not  seen  as  the  destruction  is  marked. 


102        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

The  porinanont  lesions  are  a  fibrous  nodule  in  the  simplest  cases,  but 
nuK-h  more  eommonly  a  sinus  evaeuating  into  the  sulcus  of  the  corona 
or  into  the  urethra  or  a  fistula  connecting  the  cavity  of  the  foreskin  or 
the  surface  of  the  skin  with  the  in-ethra.  The  associated  lesions  are 
regularly  those  of  the  intense  gonococcal  urethritis  which  precedes  or 
is  accomi)anied  by  these  abscesses.  The  persistence  of  the  sinuses 
and  the  tistuhe  with  little  discomfort  to  the  patient  but  with  danger 
of  autoinoculation  or  mfection  of  an  innocent  party  is  the  clinical 
importance  of  these  cases.  The  smear,  culture  and  blood-tests  for 
gonococcal  disease  should  always  be  carefully  made. 

Symptoms. — The  majority  of  these  abscesses  arise  with  local  sul)- 
jecti\'e  in^•asion  during  the  declining  stage  of  the  uretlu'itis  and  by  their 
pain,  enlargement  and  obstruction  attract  the  patient's  attentiob,  even 
before  their  full  establishment,  which  increases  these  symptoms.  The 
systemic  subject i^'e  and  objective  signs  are  not  common  but  when 
present  may  be  those  of  any  pus-focus,  chill  or  chilliness,  fever,  malaise, 
prostration  and  the  blood-count.  The  local  objective  conditions  are 
at  the  onset  a  distinct  red  spot,  like  a  pimple,  near  the  frenum  or  a 
nodule  along  the  anterior  urethra  in  front  of  the  scrotimi,  rapid  enlarge- 
ment into  a  spheroid  or  ovoid  abscess,  infolded  in  the  foreskin  with 
edema  of  moderate  or  large  extent  immediately  around  it,  and  sometimes 
obstruction  of  the  urinary  stream.  In  the  termination  complete  reso- 
lution is  the  exception,  but  the  rule  is  an  infiltration,  sinus  or  fistula 
as  described  under  pathology  and  having  the  same  clinical  importance 
for  the  patient  and  his  future  wife  already  spoken  of  under  preputial 
and  paraurethral  folliculitis. 

Diagnosis. — In  its  history  acute  periurethral  abscess  is  found  in  severe 
or  otherwise  complicated  acute  or  relapsing  chronic  urethritis  and  has 
severe  symptoms  of  swelling  of  the  urethra  downward  around  the 
corpus  spongiosum  at  any  point  and  to  any  reasonable  size,  at  first 
without  and  then  with  evacuation  of  pus,  which  recurs  intermittently. 
Downward  enlargement  is  enforced  by  the  corpora  cavernosa  penis 
above.  Pressure  on  the  swelling  in  the  early  period  develops  no  pus 
but  in  the  later  period  shows  a  spurt  of  pus  especially  if  the  urethra 
has  been  previously  washed  clean.  Urethroscopy  may  develop  the 
mouth  of  the  abscess  as  occluded  or  open. 

Chronic  Periurethral  Follicular  Abscess  presupposes  an  acute  attack 
in  its  history  with  one  or  more  abscesses  which  have  never  recovered 
and  its  symptoms  suppuration  which  is  indolent  and  persistent  or  active 
and  variable  according  to  occlusion  of  the  opening  of  the  abscess  into 
the  urethra.  Urethroscopy  will  reveal  the  infiltration  of  the  mucosa 
and  the  sinus  and  permit  with  the  ureteral  catheter  or  probe  exploration 
of  the  same  and  sometimes  recovery  of  pus. 

The  laboratory  specimen  for  smear  and  culture  of  the  gonococcus 
is  essential.  Treatment  of  the  urethritis  will  cause  minor  abscesses  to 
disappear  but  the  more  severe  ones  may  continue  after  the  urethra  is 
well  and  require  individual  management  through  the  urethroscope 
which  still  further  proved  their  nature. 


PERIURETHRAL  FOLLICULAR  ABSCESS  103 

Treatment  of  Acute  and  Chronic  Gonococcal  Periurethral  Follicular 
Abscess. — Its  significance  is  usually  minor,  but  may  in  chronic  cases 
become  major  through  absorption  and  infectiousness,  and  prevention 
suggests  gentle  means  and  no  violence  to  avoid  extending  the  infection 
into  the  glandules  of  the  mucosa.  Mild  concentration  of  fluids,  mini- 
mal force  in  irrigation  by  the  Janet  or  Chetwood  methods  or  preferably 
by  the  syringe-and-catheter  method  are  required.  Abortion  in  the  real 
sense  cannot  be  done  as  the  onset  is  masked  in  the  other  symptoms 
of  the  urethritis. 

Curative  Treatment.— Curative  treatment  is  developed  by  the  patho- 
logic and  symptomatic  indications  according  as  the  cases  are  acute  or 
chronic  and  without  or  with  a  sinus.  The  symptoms  without  sinus  for 
relief  are  pain,  enlargement,  edema  and  obstruction  and  with  sinus 
they  are  relapses  with  discharge  or  a  constant  discharge.  The  manage- 
ment embraces  the  typical  hygiene,  rest  in  bed  with  the  penis  supported, 
careful  diet  and  drink  and  regular  bowels.  Massage  is  contraindicated 
in  acute  cases  exactly  as  instrumentation  is  but  in  chronic  cases  often 
aids  with  the  sound  in  situ  to  evacuate  the  indolent  contents  of  the 
abscesses  or  sinuses  and  to  stimulate  resorption.  Hydrotherapy  is  of 
more  avail  in  acute  than  chronic  cases  to  reduce  edema  and  swelling 
and  relieve  mild  obstruction  and  consists  of  hot  penile  and  sitting  baths 
which  if  well  done  may  prevent  formation  and  rupture  of  the  abscess. 

Electrotherapy  is  contraindicated  in  the  acute  forms  but  in  the  late 
periods  is  of  value  against  the  infection  and  relapses.  The  glass  elec- 
trodes of  the  x-ray  tube  vacuum  attached  to  the  negative  pole  of  a  high- 
speed multiple  plate  static  machine  are  correct  to  employ  against  the 
organisms  while  cataphoresis  with  a  metal  electrode  attached  to  the 
positive  pole  of  the  galvanic  machine  with  a  current  of  3  to  5  milli- 
amperes  is  used  against  the  chronic  discharge  without  infection. 

Serotherapy  in  the  declining  or  sinus  stage  may  be  attempted  for 
increasing  resistance  and  immunity.  The  serum  may  be  used  earlier 
than  the  bacterin  but  without  producing  a  negative  phase  which  would 
add  to  the  progress  of  the  disease.  The  autogenous  bacterins  or  the 
heterogeneous  bacterins  will  produce  active  immunity  as  compared 
with  the  serum  and  its  passive  immunity.  The  methods  are  discussed 
in  the  section  on  Serotherapy  in  Chapter  IX  on  General  Principles  of 
Treatment  on  page  512.  On  the  whole  this  treatment  is  not  very 
satisfactory. 

Medicinal  measures  are  against  absorption,  if  present,  by  catharsis, 
diaphoresis  and  urinary  antiseptics  and  diluents  by  systemic  adminis- 
tration. If  there  is  no  sinus  the  local  measures  are  cessation  of  hand 
injection,  hot  penile  and  sitting  baths  and  hot  irrigations  when  the 
decline  appears  by  the  methods  already  described  for  the  sjTinge-and- 
catheter  inethod  under  acute  anterior  urethritis.  Nonoperative  sur- 
gery consists  in  wet  dressings  of  astringents,  antiseptics  and  sedatives 
such  as  bichloride  of  mercury,  potassimn  permanganate,  alum  acetate, 
lead  and  opium  wash  and  lead  water — often  with  improvement  in  many 
symptoms.   Catherization  may  be  gently  used  to  overcome  obstruction. 


104        COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URErilRiriS 

Oporati\o  moans  arc  oautii)us  aj^ainst  premature  and  innnature  treat- 
ment, as  OAertreatment  is  likely.  The  abscess  is  incised  through  the 
meatus  if  accessible  or  through  the  urethroscope  for  free  evacuation  of 
pus  and  instillation  of  the  cavity  with  argyrol,  nitrate  of  silver  or  iodin. 
If  the  sinus  opens  externally  it  should  be  left  alone  until  several  months 
after  the  urethritis  is  thoroughly  healed  and  all  resori)tion  ])ossible  has 
occurred.  Then  a  straight  soinid  is  passed  into  the  urethra  and  the 
sinus  or  fistula  opened  carefully  along  its  course,  previously  stained 
with  methylene  blue,  down  to  the  mucosa  and  rarely  through  it. 
Ligature  at  this  ])oint  will  sometimes  close  the  sinus  or  the  whole  mass 
may  be  dissected  free  to  the  nuuosa  and  ligated  and  moved  and  the 
defect  sutured. 

Dilatation  with  soft  sounds  during  the  subacute  or  succulent  stage 
and  with  straight  steel  sounds  during  the  late  chronic  or  infiltrating 
stage  is  indicated  for  urethral  obstruction,  but  e\'er  without  a  reaction 
such  as  pain,  bleeding  or  temporary  increase  in  the  symptoms,  because 
such  foretell  true  stricture  formation.  In  the  acute  period  a  soft 
catheter  is  used  to  draw  oii'  the  water. 

Afterfrcafnicnt  centers  on  tlie  sinus,  pocket  or  fistula  always  after 
the  urethritis  is  cured  and  the  infiltration  resorbed  as  much  as  possible. 
The  foregoing  surgical  lines  are  indicated.  Stricture  requires  dilatation 
by  mechanical  or  electrical  methods  as  detailed  in  Chapter  VII  on 
the  Treatment  of  Stricture  on  page  375.  In  all  cases  gentle  measures 
applied  at  long  sittings  and  rather  rare  intervals  are  the  preference. 

Cure  requires  relief  of  the  abscess  and  its  infectiousness  and  if  possible 
restoration  of  the  mucosa,  with  the  least  amount  of  deformity,  therefore 
surgical  methods  should  be  judiciously  performed. 

LYMPHANGITIS  AND  LYMPHADENITIS. 

Anatomy. — The  lymphatics  of  the  penis  are  according  to  Quain^  a 
dense  network  on  the  skin  of  glans  and  prepuce  and  beneath  the 
mucosa  of  the  urethra,  and  pass  chiefly  into  the  inguinal  glands.  A 
deep  system  issues  from  the  cavernous  and  spongy  body,  passes  with 
the  deep  veins  under  the  pubic  arch  and  joins  the  h'mphatic  plexuses 
of  the  pelvis. 

Significance. — These  two  complications  are  one,  as  neither  can  exist 
without  the  other  in  certain  degree.  Acute  infection  of  lymph- 
vessels  and  l\'mphglands  is  in  gonococcal  acute  urethritis  without 
mixed  pyogenic  infection  rather  rare  on  the  one  hand,  but  on  the  other 
hand  if  balanoposthitis  with  phimosis  or  paraphimosis  is  present 
such  l^Tnphatic  involvement  becomes  much  more  common.  Free 
suppuration  and  abscess  is  not  a  common  eventuality  in  the  glands. 

Ssrmptoms. — Subjective  and  objective  sATnptoms  are  pain  and  tender- 
ness along  the  lymphatic  trunks  and  over  the  glands  and  in  the  tissue 
if  cellulitis  is  imminent.  Often  red  streaks  pass  up  the  penis  marking 
the  dorsolateral  position  of  the  trunks  or  there  may  be  a  general  redness 

1  Quain's  Anatomy,  1896,  iii,  Part  4,  p.  243. 


LYMPHANGITIS  AND  LYMPHADENITIS  105 

due  to  the  cellulitis.  The  glands  are  often  enlarged,  tender  and  tense 
and  may  resolve  or  go  on  to  suppuration  marked  }>y  fhictuation  and 
adhesion,  infiltration  and  edema  of  the  skin  ov^er  the  gland. 

Diagnosis. — The  anatomical  features  have  been  sufficiently  detailed 
in  Chapter  II  on  Complications  of  Acute  Urethritis,  on  page  1(J4. 
Acute  lymphangitis  and  lymphadenitis  in  the  history  are  those  of 
acute  processes,  with  pain  along  the  penis  and  in  the  groin  on  one  or 
both  sides.  Examination  often  reveals  red,  liot,  cord-like,  tender 
streaks  passing  lengthwise  of  the  organ  and  traceable  into  the  glands 
of  the  groins  which  in  their  turn  also  become  enlarged,  hot,  tender 
and  sometimes  adherent  to  the  skin,  tense,  very  painful  and  finally 
fluctuating  if  abscess  appears. 

Laboratory  investigation  demonstrates  the  gonococcus  or  other 
organism  in  the  initial  infection  and  may  by  aspiration  with  a  fine 
needle  recover  the  same  from  the  affected  glands.  Treatment  directed 
to  the  origin  of  the  infection  may  by  prompt  and  appropriate  results 
give  still  further  proof  of  the  underlying  infection. 

Chronic  Lymphangeitis  and  Lymphadenitis. — Chronic  l}Tnphangeitis 
and  lymphadenitis  are  seen  occasionally.  The  former  with  relation  to 
urethritis  seems  rare,  although  the  latter  may  occur  in  the  strict  sense. 
What  is  seen  much  more  commonly  is  a  number  of  acute  attacks 
followed  by  infiltration  of  the  glands  and  sometimes  of  the  channels. 

Treatment  of  Gonococcal  Acute  and  Chronic  Lymphangeitis  and 
Lymphadenitis. — Their  significance  is  major  only  when  very  severe  with 
inguinal  abscess,  and  prevention  is  attention  to  the  foreskin  to  avoid 
excoriations  and  ulcerations  of  balanoposthitis  by  early  and  efficient 
treatment,  because  such  breaks  in  the  surface  become  the  foci  of 
absorption  into  the  hniphatics.  If  such  portals  of  infection  are  open 
prevention  is  difficult  against  vicious  forms  of  invasion  so  that  the 
complication  is  rarely  present  in  the  absence  of  lesions  on  the  surface 
and  of  abscesses  within  the  urethra.  The  only  abortion  is  the  wet 
dressing  with  hot  penile  baths  of  antiseptics — alimi  acetate  or  bichloride 
of  mercury  1  in  5000  changed  every  two  hours,  but  it  usually  fails. 

Curative  Treatment. — The  management  in  acute  cases  requires  good 
hygiene,  complete  rest  until  the  redness  and  tension  are  decreasing  and 
suitable  diet  and  drink  to  allay  the  irritation.  Preputial  irrigations  for 
cleansing  and  antisepsis  and  hot  penile  and  sitting  baths  as  sedatives 
and  antiphlogistics  begin  the  physical  measures. 

Heliotherapy  with  the  therapeutic  lamp  must  produce  great  redness 
of  the  skin,  but  no  pain  when  applied  several  times  a  day  for  from  ten 
to  thirty  minutes  by  the  patient  himself  up  to  the  limit  of  his  comfort. 

Medicinal  measmes  introduce  the  care  of  the  urethritis  and  balano- 
posthitis as  underlying  sources  of  _  the  IjTnphatic  involvement  as 
described  under  the  heading  of  anatomy  in  the  clinical  paragraphs 
on  this  subject.  The  preputial  irrigations  and  hand  injections  are 
continued  and  perhaps  increased  combmed  with  wet  dressings  exactly 
as  noted  in  balanoposthitis.  In  the  chronic  cases  the  glands  are  more 
apt  to  be  involved  but  the  treatment  of  chronic  phimosis  and  balano- 


106        COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

posthitis  teiuls  to  reduce  the  amount  of  absorption  by  heaUug  the  foci. 
Operative  surgery  incises  and  drains  tlie  abscess  of  tiie  inguinal  glands 
or  if  the  suppuration  is  extensive  removes  them  entirely.  Dressings  of 
the  wounds  are  on  common  surgical  lines.  A  single  gland  in  the  earliest 
stage  of  supi)uration  may  be  drained  of  its  contained  pus  by  aspiration 
followed  by  the  injection  of  10  ])er  cent,  iodoform  in  sterilized  glycerin 
only  up  to  filling  anil  not  distention  of  the  cavity.  Circumcision  must 
not  be  forgotten  as  prevention  of  subsequent  attacks  and  of  extension 
of  chronic  cases  to  suppuration. 

Aftcrtrcaimcut  avoids  a  relapse  by  the  toilet  of  the  foreskin  during 
the  remainder  of  the  urethritis  in  irrigation,  hand  injection,  lavage  and 
dressings.  Proper  treatment  of  the  urethritis  may  check  complications 
of  pus  foci  along  the  urethra,  leading  to  a  relapse.  Circumcision  is, 
as  stated,  the  i)roper  step  in  all  cases. 

Cure  requires  no  active  infiltrations  or  foci  in  the  foreskin,  urethra, 
lymphatic  vessels  or  glands,  and  full  bacteriologic  proof  of  no  infec- 
tiousness. 

GLANDULAR  COMPLICATIONS. 

Varieties  and  Importance. — Any  and  all  glands  of  the  anterior  urethra 
may  be  involved  in  gonococcal  infection  as  a  complication  of  the 
urethral  inx'asion.  This  i)ath()logical  fact  therefore  concerns  the  tubo- 
alveolar  subepithelial,  the  simple  depression,  the  submucous  glands 
and  finally  Cowpcr's  glands.  In  all  the  ducts  may  be  patent,  resulting 
in  suppuration,  with  free  discharge  upon  the  surface  or  closed,  causing 
retention  of  exudate  and  abscess  formation,  which  may  rupture 
externally  upon  the  skin  or  internally  into  the  urethra,  leaving  behind 
a  cavity,  sinus  or  fistula,  of  size  and  importance  according  to  the 
gland  affected  and  the  extent  of  the  secondary  conditions.  Cowper's 
glands  are  most  important  in  this  respect. 

The  great  number  of  small  urethral  glands  and  the  acknowledged 
frequency  of  their  invasion  and  the  relative  absence  of  subjective 
symptoms,  except  in  retention  cases,  make  these  complications  among 
the  most  important,  insidious  and  dangerous  of  the  disease  through 
tendenc}'  to  harbor  chronic  infection. 

LITTRITIS  AND  FOLLICUUTIS. 

Varieties. — The  small  mucous  glands  have  often  infection  of  two 
varieties,  without  retention  of  pus,  called  littritis  and  with  retention 
of  pus,  termed  folliculitis.  The  cause  is  intense  infection,  lowered  local 
and  systemic  resistance  and  traumatism  of  faulty  instrumentation  or 
other  local  treatment,  such  as  instillation,  irrigation  or  application. 

Pathology. — The  pathology  of  littritis  is  briefly  a  migration  of  the 
gonococcus  into  the  gland,  and  its  same  penetrating  destructive  infec- 
tion as  on  the  urethral  surface,  with  pus  usually  in  slugs  through  its 
temporary  thickening  within  the  cavity  of  the  gland.  The  wall  of  the 
gland  becomes  thickened,  so  that  on  objective  examination  they  may 
be  felt  as  little  shot-like  nodes  or  granules  scattered  along  the  urethra. 


LITTRITIS  AND  FOLLICULITIS 


107 


A  higher  grade  of  littritis,  that  is  to  say,  folHcuhtis,  adds  only  reten- 
tion of  the  pus  in  abscesses  with  thick  walls  and  final  rupture  into  the 
urethra.  The  pathology  of  folliculitis  continues  the  latter  process 
beyond  the  wall  of  the  glands  and  is  therefore  a  periglandular  and  peri- 
urethral process,  with  retention,  abscess  and  rupture  either  into  the 
urethra  or  upon  the  skin.  The  termination  of  these  glandular  com- 
plications is  usually  destruction  of  the  function  of  the  gland  and 
even  anatomical  obliteration  of  its  cavity.  More  frequently  chronic 
catarrhal  inflammation  follows  with  or  without  persistence  of  the 
gonococci.  Pus-bearing  and  urine-bearing  sinuses  and  fistulte  upon 
the  skin  are  seen. 


Fig.  20. — Gonococcal  glandular  periurethritis  or  folliculitis.     (Legueu.^) 

Symptoms. — Subjective  sjinptoms  of  littritis  are  usually  not  noticed, 
w^hile  those  of  folliculitis  may  be  swelling  and  deformity  of  the  urethra, 
usually  along  the  floor,  presenting  in  variable  size,  externally  to  that 
of  a  cherry,  and  in  different  degree  internally,  to  cause  partial  obstruc- 
tion to  urination.  The  objective  symptoms  of  littritis  may  be  absent 
or  the  nodules  along  the  floor  and  sides  of  the  urethra  whose  palpation 
is  easy  and  commonly  followed  by  expressed  pus;  while  those  of  fol- 
liculitis establish  the  abscess  or  its  secondary  purulent  or  urinary  sinus 
or  fistula.  The  termination  is  suflEiciently  described  under  pathology 
in  the  preceding  paragraphs. 

Diagnosis. — As  already  discussed  on  pages  106-108,  acute  littritis 
and  folliculitis  are  extensions  of  each  other,  the  folliculitis  being  more 
severe  than  the  littritis.  In  general  the  persistence  of  a  gonococcal 
anterior  urethritis  through  a  longer  subacute  stage  than  usual  suggests 
the  presence  of  littritis.  The  history  is  mild  in  littritis,  more  severe  in 
follicuhtis,  especially  in  the  declining  period,  when  much  more  dis- 
charge in  heavj^  shreds  is  present.  Symptoms  include  a  little  pain  and 
swelling  noticed  subjectively  and  nodules  with  little  shot-like  masses 


1  Traite  Chirurgical  d'Urologie,  1910. 


lOS        COMPLICATIONS  AND  SEQl'I^LS  OF  ACUTE  URETHRITIS 

along  tlie  urethra  ohji-ctivoly,  especially  if  an  instrument  is  in  the 
urethra  against  which  the  i)ali)atic)n  is  nuule.  Urethroscopy  will  find 
in(li\iilual  f(»llicli>  in  \arious  degrees  of  intianunation  and  recovery. 

Chronic  Littritis  and  Folliculitis  arise  from  the  acute  lesions  during 
a  severe  or  se\"eral  ri'])eated  attacks  recognized  hy  the  foregoing  diag- 
nostic details.  The  history  shows  shred  and  drop  never  absent  from 
the  in-ethra  or  lu-ine  and  the  symptoms  are  those  of  acute  attacks  simu- 
lating the  original  acute  disease  or  of  the  chronic  conditions  of  discharge, 
pasted  meatus  and  shreds.  Nodes  of  infiltration,  with  ex])ression  of 
pus,  are  ajjparent  and  the  multiple  glass  test  will  show  whether  the 
folliculitis  is  of  the  anterior,  posterior  or  anteroposterior  distribution, 
fully  ^•erified  by  the  urethroscope.  Shreds  should  be  reco\'ered  and 
sent  to  the  laboratory  for  identification  of  origin  and  bacteriology. 
Laboratory  findings  demonstrate  the  gonococcus  in  the  slugs  and 
shreds  in  the  urine  as  passed  and  in  sterile  irrigating  fluid  after  massage 
of  the  lU'ethra.  Treatment  directed  in  general  toward  the  gonococcal 
infection  removes  all  discharge  except  the  slugs  of  pus  whose  charac- 
teristics aid  in  the  diagiLosis.  Urethroscopic  applications  of  astringents, 
caustics,  electricit}'  and  lancet  renioNc  indixidual  foci. 

Treatment  of  Gonococcal  Acute  and  Chronic  Littritis  and  Folliculitis. — 
Their  significance  as  sources  of  infection  is  practically  major  in  poten- 
tiality and  prevention  in  the  acute  stages  notes  dilute  solutions  and 
conservative  methods  only  in  the  declining  period  of  the  urethritis, 
which  tends  to  avoid  driA'ing  the  infection  into  the  follicles  by  the 
injmy  of  trainnatic  dilatation  with  a  stream  under  pressure.  There 
is  no  abortive  treatment,  because  the  symptoms  are  hidden  by  those 
of  the  urethritis  and  the  nature  of  the  lesion  is  an  insurmountable 
obstacle. 

Curative  Treatmeni. — The  indications  require  respect. 

Curative  treatment  in  the  acute  stages  which  usually  are  those  of  an 
intense  tu-ethritis  with  only  the  usual  management  of  hygiene,  require 
rest  in  bed  until  the  symptoms  begin  to  decrease  and  great  attention 
to  diet  and  drink.  When  folliculitis  is  apparent  in  the  form  of  nodules 
or  tender  points  all  irrigation  and  hand  injections  should  be  temporarily 
suspended.  In  the  physical  measures,  with  a  sound  in  the  urethra 
only  during  the  chronic  stages,  massage  may  be  gently  employed  to 
stimulate  evacuation  and  resorption  while  hot  penile  and  sitting  baths 
reduce  the  edema  and  the  obstruction.  Electrothera])y  is  of  A^alue 
only  in  the  late  declining  and  chronic  periods  in  the  form  of  cata- 
phoresis  against  indolent  nonbacterial  discharge  and  in  the  form  of 
high  potential  vacuum  electrode  attached  to  the  negative  pole  of  the 
standard  multiple  plate  high-speed  static  machine.  Medicinal  measures 
are  directed  against  the  fever  and  absorption  if  present  through 
systemic  administration  in  marked  cases.  Serumthera])y  is  excellent 
in  some  individuals,  as  described  in  Chapter  IX  on  page  512, 
the  serum  tending  to  establish  passive  immunity  and  bacterins  to 
excite  active  immunity.  Locally,  in  the  acute  stages,  all.  intraurethral 
treatment  is  stopped  until  the  decline  is  well  established,  when  it  is 


COWPERITIS  109 

resumed,  at  first  with  gentle  means  and  later  with  slow  augmentation 
determined  by  reaction.  The  expectant  mctliod  is  by  all  rne;iris  7)re- 
ferred  as  irrigations  under  high  pressure  only  increase  the  pathological 
lesions.  When  chronic  manifestations  appear  the  urethroscope  is 
indicated  for  applications  of  caustics  and  the  high-fre(}uency  current 
of  Oudin,  and  .r-ray  vacuum  glass  electrodes,  with  static  electricity,  as 
already  shown  to  destroy  lurking  infection  and  finally  incision  with  the 
knife  as  required-. 

Nonoperative  surgical  treatment  in  the  acute  stages  are  w,et  dress- 
ings to  allay  suffering,  swelling,  edema  and  obstruction,  which  may  be 
relieved  by  cautious  catheterization  with  the  soft-rubber  instrument. 
Later  on  soft  sounds  or  hot  or  cold  straight  steel  sounds,  with  gentle 
massage  and  instillations  of  slowly  ascending  solutions  of  nitrate  of 
silver,  from  1  in  20,000  to  1  in  100,  with  the  soft-rubber  catheter  or 
with  the  Bangs  syringe  sound,  also  with  massage,  are  of  great  benefit. 
The  author's  irrigating  sound  in  affording  a  retrojection  as  well  as 
gentle  dilatation  should  be  used.  Operative  means  reach  the  blind 
abscess  by  incision  through  the  urethroscope  while  sinuses  and  fistulse 
are  opened  upon  a  sound  and  dissected  out  or  tied  off  exactly  as  detailed 
in  periurethral  abscess  while  contractures  of  the  canal  are  dilated 
gently  and  gradually  or  divided  according  to  indications. 

Aftertreatment. — Aftertreatment  is  concerned  with  relief  of  the 
urethritis  from  which  relapse  may  appear  in  the  follicles,  and  with 
dilatation  of  stenoses  with  soft  instruments  during  the  early  develop- 
ment and  steel  sounds  when  the  mucosa  is  dry.  A  study  of  shreds  in 
the  urine  is  the  guide  of  cure  along  with  the  author's  multiple  glass 
test. 

Cure. — The  little  pockets  should  be  free  of  infection  even  if  not  with- 
out their  drop  and  the  larger  abscesses  should  follow  the  same  course. 
Folliculitis  is  therefore  one  of  the  problems  in  urethritis  and  is  on  the 
border-line  between  minor  and  major  complications.  The  most  careful 
bacteriology  is  required  to  prove  the  cure.  Some  cases  have  a  positive 
gonococcal  complement  fixation  test. 

COWPERITIS. 

Varieties. — As  in  the  infections  of  most  glands  with  ducts  the  out- 
lets of  Cowper's  glands  may  or  may  not  become  occluded  and  thus 
arise  the  two  forms,  cowperitis  without  retention  and  cowperitis  with 
retention. 

Occurrence. — Like  the  small  mucous  glands  of  the  urethra,  Cowper's 
glands  may  be  the  subject  of  acute  complicating  involvement  of  treach- 
erous, persistently  infectious  character.  The  occurrence  is  not  common 
compared  with  littritis  and  folliculitis,  but  the  clinical  significance  on 
account  of  the  long,  tortuous  ducts  and  compound  body  of  the  glands 
is  after  their  involvement  far-reaching.  The  onset  of  the  irinfection  is 
after  acute  urethritis  has  involved  the  entire  anterior  urethra  in  full 
establishment;  that  is,  about  three  or  four  weeks  after  the  initial 


110        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

invasion.  I'siially  one,  occasionally  both  glands  simultaneously,  are 
attacked  with  an  insidious  invasion  exactly  like  the  lu'ethritis  itself 
with  at  first  relatively  few  suhjeetive  syni])toms.     The  varieties  are 


Fig.  21. — rrotcctivc  dressing  for  rectal  examination.  A  rubber  finger  cot  is  placed 
on  the  index  finger  and  over  it  is  slipped  several  layers  of  gauze,  about  six  inches  square, 
■with  a  hole  at  the  center  rather  tight  for  passage  of  the  finger.  The  gauze  receives  any 
fecal  or  infectious  matter  from  within  or  wdtho\it  the  amis. 


Fig.  22. — Is  rectal  examination,  with  the  index  finger  of  the  gloved  hand  lubricated 
and  passed  into  the  rectum,  with  the  fingers  folded  into  the  palm  and  the  elbow  sup- 
ported by  the  hip  for  force  in  penetration,  leaving  the  hand  flaccid  for  palpation. 


COWPERITIS 


]]] 


two,  determined  by  the  patency  or  occlusion  of  tlic  duct— namely, 
without  retention  and  with  retention. 

Pathology. — The  lesions  duplicate  those  found  in  and  described  for 
folliculitis  in  all  details  of  the  forms  with  and  without  retention,  except 
that  in  the  case  of  Cowper's  glands  organs  of  anatomical  instead  of 
histological  proportions  are  involved. 

Symptoms, — Cowperitis  without  Retention. — This  form  occurs  the 
more  commonly  and  is  marked  by  freedom  of  the  ducts  to  discharge 
the  pus,  actively  under  .muscular  action  or  passively  under  the  examin- 
ing finger.     The  symptoms  are  increasing  swelling,  pain  and  inter- 


FiG.  23. — Is  palpation  of  Cowper's  glands;  with  the  right  index  finger  in  the  rectum 
the  gland  is  pushed  down  against  and  between  two  fingers  of  the  left  hand,  which  permits 
thorough  digital  investigation. 


mittent  discharge,  followed  by  decrease  in  the  pain  and  enlargement 
temporarily  until  refilling  of  the  gland  occurs.  The  termination  is 
least  frequently  complete  resolution,  but  more  commonly  permanent 
damage  or  chronic  disease  of  the  gland. 

Coivperitis  tvith  Retention. — ^This  type  occurs  rather  infrequently  and 
is  really  abscess  of  Cowper's  glands,  characterized  by  closiu-e  of  the 
ducts,  retention  of  the  pus,  destruction  of  the  gland,  extension  of 
the  process  into  the  siu-rounding  tissues  and  final  ruptme,  either  upon 
the  skin  or  into  the  urethra.  At  no  time  is  active  or  passive  evacua- 
tion of  the  pus  possible  and  the  gland  is  always  damaged  beyond 
future  function  and  often  beyond  anatomical  identity.  The  abscess 
is  essentially  acute,  while  the  outcome  in  pocket,  sinus,  pm-ulent  or 


112        COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETIiniTIS 

urinary  fistula  is  chronic.  The  symptoms  are  pain  of  heavy  then  acute 
progressing  type  in  the  perineum,  accomj^anied  by  enhirgement  of 
the  ghind,  witli  later  heat,  redness,  tenderness,  fixation  and  thinning 
of  the  skin  and  tenninally  with  ru]>ture  and  evacuation,  externally 
u])on  the  skin  or  internally  into  the  canal,  which  is  followed  by  pocket, 
sinus  or  fistula  formation. 

Diagnosis. — It  is  imj^ortant  to  distinguish  the  two  forms. 

Acidc  coivperitis  ivitJioiit  rdotfion  a]>i)ears  during  a  long,'  severe 
urethritis,  as  to  its  history,  with  a  tendency  toward  other  glandnlar 
involvements  such  as  folliculitis,  and  prostatitis.  Posterior  urethritis 
is  a  feature  although  Cowper's  glands  are  at  the  bulb  of  the  urethra 
and  therefore  in  the  anterior  urethra,  but  the  infection  is  extensive. 
The  symptoms  are  severe  pain  in  the  perineum,  with  enlargement  and 
abscess,  intraurethral  rupture  through  its  own  duct  and  persistent 
evacuation.  Examination  before  evacuation  is  that  of  abscess  and 
after  evacuation  that  of  a  sac  Avhich  empties  under  pressure.  Rectal 
examination  against  a  soft  bougie  in  the  anterior  urethra  will  develop 
the  position  of  the  gland  and  its  connection  with  the  luvthra.  After 
cleansing  the  urethra  a  laboratory  specimen  may  be  obtained  by 
pressure  on  the  gland  or  through  a  urethroscope  one  may  be  secured 
with  a  swab  or  before  evacuation  aspiration  with  a  fine  needle  is 
possible  through  the  perineum.  Treatment  through  relief  of  the  ure- 
thritis may  also  subside  the  cowperitis  and  add  to  the  evidence.  IN'Ias- 
sage  of  the  gland  and  in  persistent  cases  incision  and  drainage  fix  the 
identity  of  the  condition. 

Actiie  cmvperitis  with  reicniion  is  strictly  abscess  and  essentially 
augments  all  the  difficulties  and  symptoms.  In  addition  to  the  fore- 
going facts  we  ha\'e  rupture  intraurethrally  or  extraurethrally  at 
almost  auA^  point  with  sinus  formation  in  which  a  probe  may  touch 
an  instrument  in  the  urethra.  Surgical  exploration  settles  the  matter 
and  distinguishes  it  from  other  abscesses  in  the  perineum. 

Chronic  Cowperitis  Without  and  With  Retention  is  common  on 
account  of  comj)lexity  of  the  gland  and  length  and  tortuosity  of  the  duct. 
The  history  is  that  of  acute  invasion  without  recovery  or  with  seeming 
recovery  associated  with  relapses  and  the  symptoms  are  those  of  more 
or  less  constant  indolent  discharge  in  the  type  without  retention  asso- 
ciated with  discomfort  or  consciousness  of  the  gland  or  those  of  acute 
or  subacute  relapsing  abscess.  The  infiltrated  mass  of  gland  and 
duct  is  apparent  with  sudden  expression  of  much  pus  in  each  form. 
The  urethroscope  is  of  final  diagnostic  aid. 

Treatment  of  Gonococcal  Acute  and  Chronic  Cowperitis. — Their  sig- 
nificance is  major  in  cowperitis  on  account  of  complexity  of  the  glands, 
severity  of  many  cases  and  foci  of  chronic  infection  which  the  glands 
often  become,  and  prophylaxis  is  as  against  other  complications,  care 
in  the  treatment  of  the  gonococcal  acute  urethritis  in  regard  to  the 
stages  of  this  process  and  to  observation  of  the  earliest  signs  of  the 
glandular  inAolvement.  Abortion  is  impossible  because  the  glands 
have  long  ducts  and  complicated  acini,  so  that  when  infection  has 
once  penetrated  it  cannot  be  eliminated  in  this  manner. 


COWPERITIS  "113 

Curative  treatment  during  the  acute  period  consists  in  the  approved 
management  of  hygiene,  rest  in  bed  up  to  full  subsidence  and  proper 
diet  and  drink,  with  due  sexual  rest.  In  the  chronic  form  nothing 
irritating  must  be  done,  including  sexual  activity. 

The  physical  measures  in  the  acute  stage  are  dangerous.  In  the 
chronic  stage  massage  is  of  benefit  in  evacuating  the  gland  and  in 
promoting  resolution.  ITot  rectal  irrigations,  sitting  baths  and  body 
baths  in  hydrotherapy  are  quieting  in  the  acute  stage  and  tend  to 
relieve  the  kidneys.  The  psychrophore  is  a  sedative  while  leeches  in 
extreme  cases  decrease  the  congestion.  Light  applied  from  a  60- 
candle  power  lamp  in  a  small  parabolic  reflector  for  half  an  hour  to 
an  hour  up  to  the  tolerance  of  the  patient  for  heat  and  actinic  effects 
will  relieve  the  pain  and  quiet  the  inflammation. 

The  electrotherapy  is  forbidden  by  acute  inflammation  but  accept- 
able in  dechning  and  chronic  periods  either  with  or  without  occlusion. 
It  stimulates  the  evacuation  of  pus,  the  destruction  of  infection  and 
the  restoration  of  the  infiltration.  When  infection  has  nearly  or  fully 
disappeared,  galvanic  cataphoresis  with  a  small  electrode  wound  with 
cotton  soaked  in  weak  solutions  of  zinc  chloride  or  copper  sulphate 
and  attached  to  the  positive  pole  or  in  one-tenth  to  one-fourth  strength 
of  the  tincture  of  iodin  and  connected  with  the  negative  pole  may  be 
used  in  3  to  5  milliamperes  of  current  for  five  to  ten  minutes  every 
three  to  five  days.  There  should  be  no  reaction  and  only  benefit.  If 
infection  is  present  then  the  .T-ray  vacuum  glass  electrodes  attached 
to  the  negative  pole  of  a  standard  high-speed  multiple  plate  static 
machine  is  used,  with  intensity  of  current  of  a  spark  gap  one-haK  to 
one  and  a  half  inches  for  five  or  ten  minutes  every  three  to  five  days, 
likewise  always  with  benefit  and  without  excitation.  Its  strong  actinic 
and  germicidal  effects  are  thus  localized  upon  the  glands.  Experi- 
mentally the  actinic  effects  penetrate  to  a  depth  of  from  2  to  6  mm., 
depending  on  the  intensity  of  'current  employed. 

Medical  measures  are  in  the  acute  period  little  or  none.  Locally 
ail  hand  injections  and  irrigations  should  be  stopped  and  only  external 
applications  by  the  physical  means  adopted,  including  wet  dressings 
of  lead  and  opium  wash  for  the  pain  and  of  lead  water,  acetate  of 
aluminum  and  weak  bichloride  of  mercury  for  their  antisepsis.  In 
the  chronic  stages  the  irrigations  of  the  urethra  and  instillations  as 
described  for  anterior  and  posterior  chronic  urethritis  may  heal  the 
urethra  overlying  the  gland,  but  are  without  effect  on  the  cavity  of 
the  gland,  likewise  applications  through  the  uretliroscope.  Systemic- 
ally  the  measures  previously  described  against  the  absorptive  condi- 
tions are  again  used. 

Nonoperative  surgical  means  are  contraindicated  in  the  acute  and 
cautiously  begun  and  judiciously  progressed  in  the  chronic  period. 
The  author's  irrigating  sound  is  of  advantage  in  cowperitis  without 
occlusion  and  combined  gentle  dilatation,  wdth  retro jection  of  the 
urethra  and  irrigation  of  the  bladder  against  possible  infection. 
Abscess  contraindicates  sounds  until  incision    and   drainage  relieve 


114        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

the  toii?ion.  Retention  of  urine  in  acute  cases  and  in  relapses  of 
chronic  forms  is  catheterized  \vith  a  small  soft-rubber  catheter  with 
great  gentleness. 

Operative  measures  through  the  urethroscope  on  cowperitis  with- 
out occlusion  stinuilate  the  mucosa  overlying  the  gland  while  the 
occluded  gland  must  be  incised  and  drained  whether  acute  or  chronic. 
Cyst  formation  in  the  latter  forms  is  seen.  The  technic  requires  the 
following  instruments:    The  author's  irrigating  sound,  one  scalpel, 


Fig.  24. — Abscess  of  Cowper's  gland.    Left  side,  postoperative  condition,  showing  posi- 
tion and  direction  of  the  incision.     (Hayden.') 


one  scissors,  several  small  hemostats,  ligatures,  small  sharp  and  blunt 
retractors,  probe,  director,  small  gauze  drains,  dressings  and  a  good 
T-binder — almost  duplicating  those  for  external  urethrotomy  with  a 
guide.  The  preparation  of  the  patient  and  the  field  is  the  accepted 
methods,  while  in  chronic  cases  the  anesthesia  is  local  but  in  acute 
forms  general.  The  posture  is  the  exaggerated  lithotomy  w^hile  the 
landmarks  of  the  m-ethra  are  shown  by  the  sound  and  of  the  gland 
by  the  finger  in  the  rectum.  The  superficial  field  is  the  perineum 
between  the  anus  and  the  scrotum  in  which  the  incision  is  made  over 
the  pronu'nence  of  the  swelling  down  to  the  surface  of  the  gland  in 
the  deep  field,  which  is  incised  with  scalpel  and  scissors  to  the  full 
length  of  the  skin  incision  and  gently  probed  for  pockets  and  burrows 
which  are  broken  into  the  main  cavity  with  the  blunt  point  of  an 
artery  clamp.  The  cavity  is  gently  wiped  clean  and  packed  without 
pressure  on  the  urethra.  The  author's  sound  irrigates  the  bladder 
against  infection  and  is  then  withdrawn  and  the  T-binder  is  applied 
over  the  dressing. 

1  Venereal  Diseases,  1916. 


COMPLICATIONS  OF  GONOCOCCAL  ACUTE  URETHRITIS         115 

Immediate  aflertreatment  is  dressinpj  at  regular  ii)t(;rvals  as  noedefl, 
with  renewal  of  drains  on  the  third,  fifth  or  sev(;nth  day,  and  balsam 
of  Peru  stimulating  dressings.  All  packings  arul  drainage  are  stopped 
as  soon  as  possible  and  the  dressing  is  made  light  simply  to  keep  the 
skin  open  and  avoid  a  sinus.  The  remote  aftercare  is  the  passing 
of  sounds  for  the  infiltration,  massage  and  electricity  for  resorption 
and  suitable  applications  through  instillating  sounds  and  the  urethro- 
scope for  the  bulbar  urethritis. 

Cure. — In  the  sense  of  restoring  Cowper's  glands  to  fully  normal 
condition  is  very  rare  indeed  in  either  the  form  without  occlusion 
or  that  with  occlusion  of  the  duct.  The  large  size  of  the  gland  and  its 
complicated  acini  leave  it  a  focus  of  disease  even  after  the  gonococci 
have  disappeared,  which  is  the  chief  standard  of  success.  When  this 
fails  the  complication  is  immediately  major  on  account  of  the  infection 
which  remains  years  behind  after  symptoms  have  ceased.  Cure  in 
the  sense  of  evacuating  the  pus  and  obliterating  the  gland  is  much 
more  easy  whether  in  the  period  of  obstruction  and  abscess  or  in 
the  occasional  later  period  of  cyst  formation. 

2.  Urinary  Forms. 

Inasmuch  as  anterior  urethritis  does  not  reach  the  urinary  organs 
above  the  pendulous  part  of  the  penis,  there  is  no  urinary  group  of 
complications  arising  during  its  course.  This  class  of  complication 
makes  its  first  appearance  during  posterior  urethritis,  when  that  part 
of  the  canal  in  direct  outlet  of  the  bladder  becomes  involved.  Their 
description  will  therefore  be  found  under  the  subject  of  Complications 
of  Posterior  Urethritis  on  page  162. 

B.  Systemic  Group. 

The  general  characters  of  the  anterior  urethra  and  its  glands  make 
septic  absorption  from  it  and  systemic  complications  rare  and  difficult, 
but  less  so  the  posterior  acute  and  anteroposterior  acute  lesions. 
Systemic  complications  are  most  common  in  chronic  urethritis,  under 
which  heading  they  are  more  appropriately  discussed. 

Anterior  chronic  urethritis  may  during  any  exacerbation  or  under 
any  exciting  cause  develop  an  acute  complication.  It  is  for  this 
reason  not  easy  to  draw  a  fixed  line  of  distinction  between  complica- 
tions of  acute  and  chronic  disease.  Both  forms  are  so  correlated  and 
interwoven  that  both  acute  and  chronic  complications  may  be  asso- 
ciated with  or  sequel  to  either  acute  or  chronic  uretliritis. 

n.   COMPLICATIONS   OF  POSTERIOR   GONOCOCCAL   ACUTE 
URETHRITIS. 

General  Clinical  Features. — The  complications  of  posterior  acute 
urethritis  have  the  same  clinical  peculiarities,  independently  of  cause, 
just  as  do  those  of  the  anterior  m-etlira.     In  discussing  the  latter 


IIG        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

subject  gonococcal  infection  avus  taken  as  tlie  standard  and  will  be 
again  in  connection  with  tlie  ]M'esent  matter,  because  its  tN^^e  is  the 
most  nmnistakable. 

Varieties. — The  general  classes  are  local,  aft'ecting  the  urinary  -and 
sexual  organs  only,  and  s>'steniic,  reaching  the  body  at  large  in  particu- 
lar systems  or  in  general.  The  local  or  urogenital  complications  in 
anatomical  order  are  the  sexual:  prostatitis,  vesiculitis,  funiculitis, 
epididymitis  and  orchitis;  and  the  urinary:  cystitis,  retention  of  urine, 
ureteritis,  pyelitis  and  pyelonephritis. 

The  systemic  or  extraurogenital  group  embraces  cutaneous,  diges- 
tive, circulatory  (including  inetastatic  abscesses),  respiratory,  special 
sensory  and  locomotor  (including  bone,  articular,  muscular  and  teno- 
synovial) complications,  and  are  discussed  in  Chapter  III  on  page  201. 

There  are  no  urinary  or  systemic  complications  of  anterior  acute 
urethritis,  as  stated  in  the  introductory  paragraphs  of  this  section. 
These  two  groups  are  therefore  properly  considered  under  posterior 
urethral  lesions. 

A.  Urogenital  Group. 

Varieties. — Two  groups  are  recognized:  sexual  and  urinary.  Of 
these  all  not  only  may  be  acute  complications  during  posterior  gono- 
coccal acute  lu-ethritis,  also  may  be  acute  complications  during  exacer- 
bations or  dining  the  ordinary  course  of  posterior  gonococcal  chronic 
urethritis.  The  sexual  group  comprises  prostatitis,  seminal  vesiculitis, 
funiculitis,  epididymitis  and  orchitis.  The  last  three  are  so  closely 
related  as  to  be  considered  usually  under  the  one  subject  of  epididy- 
mitis. The  urinary  group  includes  urethrocystitis,  cystitis,  retention 
of  urine,  ureteritis,  pyelitis  and  pyelonephritis. 

1 .  Sexval  Forms. 

For  the  sake  of  convenience  the  anatomical  order  will  be  followed 
and  the  comparati^'e  frequency  of  occurrence  will  be  noted  under  each 
example. 

PROSTATITIS. 

Occurrence  and  Etiology. — Infection  of  the  prostate  through  its 
position  and  connection  by  ducts  with  the  posterior  urethra  occurs  as 
a  very  common  complication  of  posterior  acute  urethritis  or  during  an 
acute  exacerbation  of  chronic  disease  or  as  an  acute  condition  in  the 
course  of  chronic  urethritis,  as  will  be  later  discussed.  The  exciting 
cause  is  direct  extension  in  continuity  of  mucosa  of  severe  infection 
with  or  without  associated  pus  organisms.  All-important  predispos- 
ing factors  are  catarrhal  prostatitis  of  venereal  excess  and  masturba- 
tion, irritation  l)y  alcoholism  and  condiments  and  traumatism  by 
faulty  treatment  and  agitation  by  railroad,  automobile,  bicycle  and 
horseback-riding.  Varieties  are  acute,  subacute  and  chronic,  of  which 
the  last  will  be  discussed  as  cognate  with  chronic  urethritis  in  a  later 
chapter. 


PROSTATITIS  117 

Gonococcal  Acute  Prostatitis.—  Varieties. — Acute  coinplicating  pros- 
tatitis shows  two  forms  accordin^^  to  the  portion  of  the  gland  involved, 
namely,  follicular  or  glandular  prostatitis,  in  which  acini  and  ducts 
alone  are  involved,  and  parenchymatous  or  phlegmonous  j)rostatitis 
(abscess  of  the  prostate),  in  which  the  gland-tissue  as  a  whole  in  one 
or  more  parts  is  destroyed. 

Pathology. — Acute  follicular  iirodatili'i  is  that  of  mild  congestion, 
with  full  recovery  or  that  severe  suppuration  involving  the  ducts  and 
the  acini  usually  without  retention  so  that  the  pus  is  evacuated  spon- 
taneously into  the  urethra.  The  acini  and  ducts  may  recover  fully 
or  be  permanently  damaged  and  obliterated  or  become  the  seats  of 
chronic  foci  of  infection. 

Subacute  follicular  'prostatitis  has  the  same  lesions  as  the  acute  type 
but  in  much  milder  degree,  owing  to  the  fact  that  it  commonly  arises 
through  causes  other  than  severe  infection,  such  as  exposure,  vicious 
habits  and  faulty  treatment.  Chronic  follicular  prostatitis  is  usually 
the  outcome  of  the  more  severe  suppurative  forms,  but  occasionally 
the  subacute  type  also  becomes  chronic.  Each  follows  the  tendency 
of  its  own  preliminary  form  in  that  the  follicles  chronically  diseased 
continue  either  suppurative  or  catarrhal,  as  the  case  may  have  been  at 
the  outset.  Suppurating  follicles,  however,  may  eventually  lose  their 
pus  but  retain  their  mucous  discharge.  This  subject  is  further  treated 
in  the  Chapter  on  Complications  of  Chronic  Gonococcal  Urethritis. 

Acute  Parenchymatous  Prostatitis. — ^The  abscess  is  mild,  severe  or 
intense  in  degree  according  to  the  activity,  extent  and  complications  of 
the  lesions.  It  is  caused  by  follicular  infection,  penetrated,  extended 
and  involved  in  the  stroma  as  well  as  in  the  glandular  elements 
of  the  prostate,  with  resulting  abscess.  In  site,  the  abscess  may  be 
superficial  or  deep,  in  any  lobe  or  lobes  or  in  the  gland  as  a  whole, 
and  may  vary  in  number  from  single  to  multiple,  with  a  tendency  to 
coalesce  into  one  common  cavity,  and  may  differ  in  size  from  that  of 
peas  to  eggs  containing  from  a  few  to  250  c.c.  of  pus.  The  contents  may 
be  pure  pus  or  a  mixture  of  detritus,  pus  and  blood  without  odor  or 
very  foul  from  the  presence  of  Bacillus  coli  communis.  In  termination 
the  phlegmon  evacuates  according  to  its  site  and  the  periprostatic 
infection:  (1)  internally  into  the  urethra,  bladder,  vesicorectal  space, 
rectum  and  peritoneum,  and  (2)  externally,  usually  upon  the  skin  of  the 
perineum.  The  complicating  lesions  of  prostatic  abscess  are  due  to 
penetration  into  or  association  in  the  periprostatic  spaces  of  the  initial 
infection,  with  burrowing  of  the  pus  determined  largely  by  the  original 
sites:  (1)  backward  into  the  rectum  by  abscesses  originally  near  its 
cavity;  (2)  downward  into  the  perineum,  sheath  of  the  penis  or  scrotmn ; 
(3)  laterally  into  the  ischiorectal  fossae  and  thigh,  and  (4)  upward  upon 
the  loins  and  back.  Pockets,  sinuses  and  seminal,  urinary  or  fecal 
fistulas  are  often  the  sequels  of  such  complications. 

Symptoms. — The  symptoms  of  acute  follicular  i^rostatitis  vary  with 
the  degree  of  the  infection,  being  less  in  the  superficial  follicular  and 
subacute  cases  and  greater  in  the  deeper  follicular  and  parenchymatous 


lis      coMPLiCArinxs  axd  sequels  of  acute  urethritis 

and  acute  forms.  They  are  local  ami  systemic,  subjective  and  objec- 
tive in  distinction.  The  local  subjective  symptoms  are  (1)  sensory: 
pain  and  weight  in  the  perineiun,  rectum  and  bladder  in  the  deep  pelvis 
or  referred  down  the  thighs  and  into  the  loins  nnich  as  uterine  jiain  in 
the  female,  and  ('2)  vesical:  dysuria,  i)ollakiuria,  tenesnms  through 
congestion  and  irritation,  and  retention  of  urine  by  edema  or  spasm; 
(3)  sexual:  chordee  and  painful,  blootly,  seminal  emissions,  and  (4) 
rectal:  pain  in  defecation,  altered  stools  and  obstipation,  through 
mechanical  i>ressurc  and  tenesmus  tln-ougli  reflex  action  or  peri])rostatic 
invasion. 
The  local  objective  symptoms  are  urinary  and  rectal. 

1.  Urinari/  Signs. — All  test-glasses  of  urine  are  filled  with  i)us,  but 
the  last  often  with  slugs  of  prostatic  detritus  and  blood. 

The  seven-glass  test  of  the  author  may  be  done  with  caution  in  the 
less  severe  cases.  It  ^^"ill  show  large  amounts  of  pus  in  the  first  three 
glasses.  Only  the  fourth  or  bladder  glass  secured  with  the  catheter  will 
be  fiee  of  abnormal  constituents  unless  the  bladder  and  other  urinary 
organs  are  infected.  If  gentle  massage  of  the  prostate  is  made  the  fifth 
or  massage  glass  will  be  loaded  with  the  expressed  contents  of  those 
follicles  ^^■hic•h  haxe  not  been  occluded.  The  sixth  and  se\'enth  glasses 
are  again  negative  if  both  seminal  vesicles  have  escaped  involvement. 
The  technic  of  the  scAcn-glass  test  is  described  in  the  Chapter  on  Pos- 
terior Chronic  Urethritis  on  page  291.  In  the  more  se\'ere  cases  the 
four-glass  test  is  of  much  value.  The  prostatic  products  in  the  third  or 
posterior  urethral  glass  and  in  the  fom-th  or  prostatic  massage  glass 
make  the  diagnosis.  Passage  of  catheters  in  these  intense  cases  for  a 
bladder  specimen  is  contraindicated. 

2.  Rectal  Sicpis. — Through  the  rectum :  The  prostate  is  hot,  enlarged, 
tense,  fluctuating  at  various  points  or  in  the  A\hole  body  of  the  gland 
and  tender,  obstructing  the  rectum  more  or  less  completely  and  the 
periprostatic  tissues  may  be  boggy  or  infiltrated.  Vesical  and  rectal 
tenesmus  follow  examination.  Instrumental  urethral  examination 
is  contraindicated  except  to  relieve  retention.  The  subjecti\'e  and 
objective  systemic  sj'mptoms  are  chill  or  chilliness,  fever  from  100° 
to  105°  F.,  prostration,  depression,  nausea,  vomiting,  blood-count  * 
tj^Dical  of  active  pus  processes  and  willing  confinement  to  bed  for  many 
days.  Severe  lesions  cause  extreme  suftering,  almost  more  than  any 
other  destructi\e  pus  condition  in  any  organ,  ^^'hen  the  pus  is  actually 
present  all  symptoms  are  greatly  augmented. 

The  termination  is  in  mild  cases  always  slow,  but  usually  complete 
recovery.  In  the  more  se^■ere  cases  follicles  may  be  destroyed  and 
obliterated  or  go  on  to  chronic  catarrhal  or  sujipuratiAc  infiammation, 
which  may  last  for  years  or  life.  The  ducts  of  such  follicles  are  patulous 
in  the  field  of  the  urethroscope  and  often  discharge  clouds  and  slugs  of 
pus  while  under  observation. 

Subacute  FoUiciiIar  Pni.statitis. — This  is  very  similar  in  kind  but 
much  less  in  degree  and  concerns  primary  and  secondary  cases.  The 
primary  cases  are  caused  by  the  improper  use  of  irrigations,  injections, 


PROSTATITIS  110 

catheters,  sounds,  urethroscopes,  cystoscopes  and  lilliotrites  and  the 
secondary  cases  arise  during  a  i)osterior  urethritis  or  after  excesses  in 
alcohol,  food,  coitus,  ma-iturbation  and  exercise.  The  termination  is 
usually  complete  recovery  after  withdrawal  of  the  cause,  particularly 
improper  medication  and  instrumentation. 

Acute  Parenchymatovs  Prostatitis. — This  very  important  disease 
follows  mild,  severe  and  intense  courses  in  accordance  with  the  number, 
size  and  destructiveness  of  the  abscesses  and  the  complications.  Pain 
in  the  prostate  is  severe,  augmenting  with  the  progress  of  the  pus, 
throbbing  and  heavy  in  character,  often  referred  along  the  penis  and 
urethra  and  backward  into  the  lumbar  regions.  Obstruction  of  the 
rectum  is  marked.  The  urinary  symptoms  are  severe,  scalding  polla- 
kiuria,  dysuria,  even  drop  by  drop  and  retention  by  edema.  The 
urethra  is  obstructed  to  the  catheter  even  to  10  or  12  French  and 
naturally  deviates  away  from  the  point  of  greatest  enlargement.  The 
rectal  symptoms  are  obstipation,  stools  compressed  to  "ribbons"  or 
scybala  and  the  gland  greatly  enlarged  into  the  rectum  as  a  general 
abscess  or  as  multiple  soft  foci  or  a  urethral  submucous  abscess,  difficult 
to  distinguish  positively.  The  sexual  symptoms  are  commonly  wanting, 
owing  to  the  pain  which  inhibits  the  spinal  reflexes;  but  if  present 
they  are  scalding,  bloody,  purulent  emissions. 

The  systemic  symptoms  are  those  of  intense  pus  focus  an}T\'here  in 
the  body,  with  active  absorption.  Typhoid  fever  is  not  uncommonly 
wrongly  suspected  as  present  in  these  cases  on  account  of  their  active 
septicemic  condition  and  prostration  and  may  be  disproved  only  by  the 
absence  of  the  Widal  reaction  in  the  blood  and  the  t^q^hoid  bacilli  in 
the  blood  and  excreta.  The  symptoms  are  therefore  severe  and  often 
recurring  chills  rather  than  mere  chilliness,  fever  of  sudden  appearance 
and  wide  variations,  rapid  high-tension  pulse,  profuse  perspiration, 
depression  and  a  septic  exhausted  appearance. 

The  termination  is  usually  spontaneous  or  operative  evacuation,  with 
prompt  positive  decrease  of  all  sjonptoms.  Natural  pointing  of  the  pus 
is  in  the  line  of  least  resistance,  and  as  described  under  Pathology  may 
be  devious  and  unexpected,  leaving  behind  chronic  pockets,  sinuses  and 
urinary,  seminal  or  fecal  fistulae.  Death  from  septicemia  is  rather 
common  in  neglected  cases. 

In  general,  infection  of  the  prostate  is  a  serious  and  long-continued 
condition,  owing  to  the  complexity  and  delicacy  of  the  gland  itself  as 
shown  in  its  embryological  foundations  and  owing  to  its  direct  connec- 
tion with  the  posterior  urethra  which  is  in  itself  so  often  the  site  of 
chronic  infection. 

Diagnosis. — ^It  is  essential  to  determine  the  form  of  prostatitis  present. 

Acute  and  subacute  follicular  prostatitis  present  intense  invasion  of 
the  urethra,  in  their  histories,  with  rapid  extension  into  the  posterior 
portion  and  with  signs  of  vesical  irritation,  active  and  persistent. 
Subacute  forms  are  the  milder.  Local  sjTnptoms  are  sensory,  vesical, 
sexual  and  rectal,  subjectively,  with  a  tendency  to  focalize  in  the 
prostate,   and  objectively  the  multiple  glass  tests  (without  use  of 


120        COMPLICATIOXS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

catheter  in  the  bladder)  show  the  posterior  urethral  glass  and  the 
massage  glass  full  of  jnis  and  prostatic  elements  through  muscular 
action  of  the  neck  of  the  bladder  and  the  urethra  and  by  the  compres- 
sion of  the  massage.  Through  the  rectum  all  signs  of  infection,  infil- 
tration and  obstruction  are  present.  Systemic  symptoms  are  those  of 
infection,  fever,  chill,  prostration  and  blood  count.  For  the  laboratory 
a  specimen  ma>'  be  obtained  after  gentle  irrigation  of  the  anterior 
urethra  by  massage  followed  by  cA'acuation  of  the  bladder,  and  will 
contain  the  gonococcus  for  smear  and  culture  associated  with  many 
prostatic  elements.  This  complication  sometimes  gives  a  positive 
complement  fixation  test  early.  Treatment  by  securing  subsidence  of 
the  anteroposterior  urethritis  benefits  the  prostatitis  indirectly,  but 
direct  treatment  of  the  gland  with  massage,  rectal  irrigations  and 
sometimes  electrical  applications  proves  the  lesion. 

Acute  iKireiichyinaioiis  prostatitis  duplicates  and  augments  all  the 
foregoing  symptoms,  and  develops  a  large  focus  of  pus  in  one  or  both 
lobes  or  the  gland  as  a  whole  with  characteristic  symptoms.  In  all 
forms  of  acute  prostatitis  urethroscopy  and  other  forms  of  instrumen- 
tation arc  contraindicated. 

Gonococcal  Chronic  Prostatitis.- — Differences  in  degree  mark  chronic 
catarrhal  from  chronic  siippiu'ative  forms  as  their  general  character 
is  much  the  same.  The  history  marks  the  catarrhal  cases  as  originating 
in  diatheses,  in  indiscretions  as  to  diet,  drinking  and  sexual  intercourse 
and  in  frequent  attacks  of  lu-ethritis  which  leave  the  sunpler  inflam- 
mation behind  them  without  true  suppurative  prostatitis.  The  gono- 
coccal prostatites,  however,  have  a  record  of  one  or  more  definite 
mvasions  of  the  organ,  with  follicular  (less  severe)  or  parenchymatous 
(more  pronounced)  manifestations.  The  subjective  symptoms  are 
therefore  in  definite  or  marked  sensory,  sexual,  vesical  and  rectal 
disturbance.  Leaking  from  the  urethra  during  defecation  contains 
mucus  or  pus  according  to  the  catarrhal  or  pyogenic  lesions.  The 
objecti\e  signs  comprise  the  findings  in  the  seven-glass  test  folknved  by 
laboratory  examination  and  the  conditions  of  the  prostate  on  bimanual 
or  unimanual  examination.  Catarrhal  prostatitis  gives  universal 
softness,  follicular  prostatitis  contains  spots  of  softening,  with  purulent 
discharge  and  parenchymatous  prostatitis  has  one  or  more  large  points 
of  softening,  due  to  abscess.  The  periurethral  method  consisting  in 
passing  a  soft  woven  lisle  thread  or  silk  catheter  into  the  bladder  and 
examining  the  prostate  around  it  should  be  employed  only  by  those  of 
great  skill  and  caution  in  obsciu'e  cases. 

As  to  the  objective  signs,  Schlagintweit^  states  the  following  phe- 
nomenon: During  massage  of  the  prostate  the  patient  holds  below  the 
meatus  a  tumbler  filled  with  water,  in  order  to  catch  the  outflow  of  the 
secretion.  Drops  massaged  out  of  the  lower  portions  of  the  prostate  in 
the  immediate  neighborhood  of  the  anus  fall  from  a  height  from  5  to 
10  c.c.  to  the  surface  of  the  water,  where  they  dissipate  themselves  in 

1  Nitze-Oberlaender's   Centralblatt,    1901,    p.    173. 


PROSTATITIS  121 

so  far  as  they  consist  in  normal  thin  secretion  of  the  gland.  The  rc^suJt 
is  a  slight  opalescence  imparted  to  the  water  exactly  hke  that  seen  in  tli(; 
urine  after  massage  of  the  prostate.  Those  drops  of  the  fluid  expressed 
which  contain  pus  sink  to  the  bottom  of  the  glass  as  thick  flocculent 
masses.  The  drops,  however,  which  are  brought  away  from  the  upper 
part  of  the  prostate,  which  have  subsequently  been  shown  to  arise  from 
the  seminal  vesicles,  cling  in  formed  condition  to  the  upper  level  of  the 
water  and  gradually  elongate  themselves,  in  accordance  with  their 
thickness  and  weight,  into  longer  or  shorter  mollusk-like  floating 
saccules  or  vessels. 

Oberlaender  and  Kollmann^  say  that  the  surest  and  safest  diagnostic 
proof  of  prostatitis  is  the  microscopic  findings  in  the  secretion  expressed. 
Normal  prostatic  secretion  consists  chiefly  of  masses  of  lecithin  kernels 
and  scattered  epithelial  cells.  The  secretion  of  prostatitis  contains  in 
accordance  with  the  severity  of  the  inflammation  admixture  of  pus  with 
the  normal  fluid  or  consists  of  pure  pus.  Seminal  crj^stals  and  amyloid 
bodies  are  not  constant  factors.  Spermatozoa  are  found  only  when  the 
seminal  vesicles  and  the  ejaculatory  ducts  are  victims  of  the  inflamma- 
tion. The  microscopic  findings  are  shown  in  the  normal  secretion  and 
of  mild  and  severe  inflammation  of  the  glands.  The  laboratory  analysis 
obtained  by  irrigation  of  the  urethra,  massage  of  the  prostate  and 
centrifugation  of  urine  embraces  bacteriology  for  the  gonococcus  and 
other  organisms  in  sterile  specimens  and  the  gonococcal  fixation  test. 
The  treatment  usually  involves  easy  distinction  of  the  fact  of  prosta- 
titis and  of  one  form  from  another. 

According  to  Young^  the  relation  of  leukocytes,  pus  cells,  epithelia, 
spermatozoa  and  bacteria  in  expressed  prostatitic  fluid  is  the  deciding 
factor.  This  contribution  by  Young  is  fully  discussed  on  page  318, 
under  the  subject  of  chronic  prostatitis  as  a  complication  of  posterior 
chronic  urethritis. 

Treatment  of  Gonococcal  Acute  and  Chronic  Prostatitis. — ^^Yith  due 
regard  to  significance,  this  complication  is  distinctly  major  because  it 
usually  involves  the  gland  deeply,  may  lead  to  absorption  and  rhemna- 
tism,  and  not  infrequently  to  an  important  operation.  The  varieties 
of  follicular  and  parenchymatous  prostatitis  are  considered  together 
because,  like  the  symptoms,  the  treatment  is  usually  one  of  differences 
in  degree  only  and  not  in  kind. 

The  prophylaxis  is  only  concerned  with  the  same  measures  of  pre- 
vention available  in  all  other  complications  of  gonococcal  disease,  such 
as  caution,  care,  conservatism  and  judgment  in  the  treatment  of  the 
anteroposterior  urethritis.  Most  important  is  the  instrmnentation  of 
the  urethra  during  the  disease.  In  doubt  it  had  best  be  omitted.  Like- 
wise the  physical  methods  especially  massage  and  electrotherapy  if 
begun  too  early  and  carried  on  improperly  may  induce  a  follicular  or 
parenchymatous  involvement  otherwise  avoidable.     Abortion  in  the 


1  Die  chronische  Gonorrhoe  der  mannlichen  Harnrhohre,  Zweite  Auflage,  1910. 

2  Johns  Hopkins  Hospital  Reports,  No.  xiii. 


122        COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

strict  sense  cannot  l)t'  accomplisliocl  because  the  symptoms  of  the 
prostatitis  merge  imlefinitely  with  those  of  the  urethritis. 

Curaiivc  Trcattiwnt. — All  measures  are  founded  on  inter])retatiou  of 
indications  and  ])roper  choice  and  ai)])lication  of  the  \arious  means 
at  ccunnuukl. 

The  essentials  of  management  are  described  in  ('liai)ter  IX,  page 
4S3,  on  General  Principles  of  Treatment. 

Of  ])hysical  measures  in  acute  follicular  prostatitis  massage  is  contra- 
indicated,  but  in  the  subacute  stages  is  valuable  and  in  the  chronic 
stages  is  ad\-isable  for  emptying  the  acini  of  pus  and  thus  giving  them 
^estorati^•e  impidse.  In  parenchymatous  prostatitis  massage  is  a 
danger — by  extending  the  abscess  through  trauma.  A  chronic  abscess 
with  sinus,  while  awaiting  oi)eration,  may  be  tem])orarily  benefited  by 


Fig.  25. — Rectal  examination  of  the  prostate.  The  patient  is  in  the  knee  or  knee- 
chest  posture  on  the  table.  The  elbow  of  the  examiner  rests  on  the  side  of  hip  and  the 
body  gently  presses  the  hand  deeply  into  the  perineum  while  the  finger  is  relaxed  and 
free  of  strain  to  make  the  exploration  of  the  prostate  gland,  seminal  vesicles  and  lower 
bowel. 

judicious  evacuation  and  absorption  from  it  thus  limited.  Massage 
is  best  performed  with  the  bladder  full  and  the  patient  stooping  over 
a  chair  or  ta})le.  The  well  lubricated  glove  index  finger  is  inserted  into 
the  rectum  w^hile  the  forearm  is  supported  by  the  hip  for  penetration 
(Fig.  25%  The  ducts  of  the  gland  radiate  more  or  less  in  orderly 
manner  from  the  colliculus  and  the  prostatic  fossettes.  All  pressure 
should  therefore  be  exerted  from  the  lateral  borders  toward  the  urethra 
and  the  author  begins  at  the  lateral  border  and  at  the  base  of  the  gland 
and  then  steadily  passes  his  finger  toward  the  urethra  along  the  upper 
border,  then  on  the  same  side  a  centimeter  in  front  of  the  first  zone,  and 
then  a  similar  distance  in  front  of  the  second  zone  until  the  apex  of  the 
gland  is  reached.  Thus  one  lateral  half  is  completely  evacuated  and 
the  second  lateral  half  of  the  gland  is  treated  in  exactly  the  same 


PROSTATITIS  123 

manner.  Thus  the  anatomical  structure  is  carefully  respected  arifl  the 
normal  physiology  reasoiial)ly  imitated. 

The  hydrotherapy,  locally,  during  the  acute  period  forbids  all 
urethral  and  vesical  irrigation  unless  acute  retention  of  urine  shall  have 
made  the  gentle  passing  of  a  small  soft  rub})er  catheter  necessary. 
While  the  catheter  is  in  situ  the  bladder  should  be  protected  against 
infection  by  irrigation.  Rectal  lavage  with  hot  water  through  the 
double  current  tube  and  with  hot  or  cold  water  through  the  psychro- 
phore  and  the  ice-bag  to  the  perineum  with  protection  of  the  testicles 
against  the  cold  and  to  the  suprapubic  region  are  comforting.  Very 
hot  sitting  baths  and  leeches  directly  decongest  the  deep  pelvic  cir- 
culation. All  these  measures  quiet  the  hyperemia  and  disturbance  and 
thus  reduce  the  pain,  irritability,  reflex  symptoms  of  the  acute  and 
subacute  periods  but  are  of  little  value  in  the  chronic  stages.  General 
hydrotherapy  is  of  little  importance  in  the  acute  period  but  otherwise 
in  the  subacute  and  especially  in  the  chronic  stages.  Bodily  baths  and 
Turkish  baths  aid  in  elimination  of  the  septic  absorption  so  often  seen 
in  the  recovery  after  operation. 

The  application  of  light  through  its  heat  and  in  actinic  power  in  acute 
onset  will  decrease  the  pain  and  in  the  chronic  stages  aid  in  resorption. 
It  requires  prolonged  application  by  the  patient  or  attendant  several 
times  a  day  and  will  aid  the  other  methods,  but  is  of  itself  not  sufficient. 
Its  convenience  of  use  makes  it  more  attractive  than  hydrotherapy. 

The  electrotherapy  is  obviously  impossible  in  the  acute  period,  but 
is  applicable  during  the  late  subacute  and  chronic  stages.  Its  local 
means  are  chiefly  rectal  by  the  high  vacuum  glass  electrode,  attached 
to  the  negative  pole  of  a  standard  multiple  plate,  high-speed,  static, 
electrical  machine  for  its  powerful  actinic  and  mild  .r-ray  effects. 
In  persistent  infection  the  spark  gap  is  from  one-half  to  one  and  a 
half  inches  for  the  intensity  of  the  current,  five  to  ten  minutes  are  the 
duration,  and  every  other  day  at  first  and  then  longer  intervals  are 
the  frequency.  When  the  infection  is  cured  the  static  wave  current 
is  applied  through  the  metal  electrodes,  attached  to  the  positive 
pole  of  the  same  static  machine,  with  a  spark  gap  of  from  one  inch 
to  six  inches  for  intensity,  according  to  the  resistance  of  the  patient, 
with  twenty  minutes  as  the  limit  of  duration,  and  with  alternate 
days  as  the  early  and  longer  intervals  as  the  later  frequency.  Easy 
count  of  the  interruptions  by  the  spark  gap  is  the  standard.  Thus 
are  gained  alternate  physiological  tissue  contraction  and  relaxation  in 
a  way  that  is  not  possible  with  the  finger  in  massage.  Electrolysis 
through  galvanism  is  the  only  way  in  which  this  modality  may  be 
applied  to  the  deep  urethra  with  the  copper  or  silver  tip  electrodes. 
Intensity  is  from  3  to  5  milliamperes,  five  to  ten  minutes  are  the  dura- 
tion and  every  other  day  is  the  early  frequency  followed  by  more 
extended  intervals.  The  positive  pole  is  attached  to  the  electrode  and 
the  current  induces  a  deposit  of  the  metal  in  the  tissues.  The  current 
should  be  turned  off  before  the  electrode  is  removed,  and  if  there 
seems  to  be  spasm  or  adhesion  the  polarity  should  be  reversed,  either 


124        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

or  both  difficulties  are  corrected  by  loosening  of  the  electrode.  Cata- 
phoresis  cannot  be  carried  on  in  the  deep  urethra  hocauso  an  electrode 
wound  with  cotton  cannot  be  introduced  there,  lliuh-frcciucncy  cur- 
rent of  Oudin  is  applied  to  iniHvidual  follicles  in  the  chronic  i)eriod 
through  tlte  urethroscope  as  dctailctl  under  that  subject. 

The  systemic  electrotherapy  is  available  for  stimulating  elimination, 
digestion,  circulation  and  the  nervous  system  as  discussed  under  the 
l)aragra])hs  de\otc(l  to  systemic  a])i)lication  in  the  electrical  treatment 
of  acute  urethritis  on  page  2S1. 

Medicinal  measures  are  of  little  avail  in  the  acute  or  in  the  chronic 
stages  by  systemic  administration.  Sedatives  are  required  for  the  pain 
in  the  form  of  o]Mum  suppositories,  codein  by  mouth  and  hypodermic 
injections  of  morphin  for  the  urinary  disturbance  through  dilution  and 
neutrality  of  the  urine  by  drinking  water  and  any  of  the  standard 
prescriptions  already  stated,  and  for  the  sexual  irritation  by  instruction 
to  keep  the  bladder  and  the  rectum  empty.  The  })ollakiuria  always 
keei)s  the  bladder  empty  in  the  acute  stages,  but  in  the  chronic  i)eriods 
such  directions  are  necessary.  The  rectal  distress  is  aided  by  the 
foregoing  measures.  The  serotherapy  may  be  tried  in  the  acute  and 
avails  in  some  cases,  but  fails  in  many,  and  is  not  in  gonococcal  disease 
the  magical  relief  which  it  is  in  diphtheria,  for  example.  In  general,  the 
serum  tends  to  promote  passive  immunity  in  acute  conditions  and  the 
bacterin  to  establish  active  immunity.  The  latter  preparation  may 
be  autogenous  or  heterogeneous  and  is  of  more  service  in  the  chronic 
absorptive  conditions,  but  by  no  means  invariably  so.  Persistent 
use  with  other  means  secures  success,  and  the  negative  phase  must  be 
avoided  as  detailed  in  Chapter  IX  on  General  Principles  of  Treatment 
in  the  section  on  Serumtherapy  on  page  512. 

The  mixed  bacterin  of  Van  Cott  is  often  very  serviceable  in  cases 
having  the  mixed  infection  and  acti^'e  al)soiption. 

The  local  administrations  are  omitted  during  acute  follicular  pros- 
tatitis as  all  invasion  of  the  posterior  urethra  must  be  abandoned  until 
the  declining  period  is  well  established.  Irrigation  of  the  bladder  after 
catheterization  for  acute  retention  and  retrojection  of  the  urethra, 
with  the  antiseptic  contents  of  the  bladder  as  part  of  this  process,  is 
an  exception  of  this  rule.  Instillations,  at  first  with  the  soft-rubber 
catheter  and  later  with  the  Bangs  syringe  sound  or  the  Keyes-Ultzmann 
syringe,  Avith  very  dilute  and  then  slowly  ascending  standard  solutions, 
are  valuable,  but  often  reach  only  the  surface  of  the  mucosa  and  not 
the  depths  of  the  follicles.  They  may  be  called  "blanket  applications" 
in  covering  a  large  area  without  definite  localization  or  penetration. 
Later  in  the  chronic  stage,  applications  of  astringents  and  antiseptics 
to  individual  follicles  through  the  urethroscope  are  good,  as  discussed 
under  this  subject. 

In  the  acute  and  chronic  parenchymatous  prostatitis  local  metlica- 
tion  is  practically  fruitless,  because  the  abscess  is  deep  under  the 
mucosa  beyond  their  reach. 

Nonoperative  surgical  measures  are  advisable  and  serviceable. 


PROSTATITIS  125 

Acute  Follicular  Prostatitis.- — For  retention  of  urine,  catheterization 
is  foremost,  with  a  soft -rubber  catheter,  which  should  be  tied  in  order 
to  avoid  frequent  invasion  of  tlie  viscus.  In  th(;  later  chronic  p(;riod 
instillations  and  retrojections,  as  already  discussed,  are  noted.  The 
author's  irrigating  sound  is  of  special  service  when  dilatation  becomes 
indicated,  because  it  combines  retrojection  with  it  at  one  passage  of 
the  instrument.  Similarly  the  Bangs  instillatiiig  sound  may  be  used 
for  focal  medication  and  for  mild  massage,  with  the  instrument  in 
place,  but  only  in  chronic  follicular  cases.  The  Kolhnann  irrigating 
and  nonirrigating  dilators  are  also  available,  but  only  with  the  greatest 
possible  gentleness  and  in  the  latest  period  of  the  disease  always 
without  any  reactions. 

Parenchymatous  Prostatitis. — ^All  these  methods  are  of  avail  only 
in  the  postoperative  stage,  when  the  chronic  urethritis  associated 
with  the  prostatitis  requires  treatment  of  the  mucosa. 

Operative  Procedures. — ^These  are  chiefly  urethroscopic  measures  and 
open  operation. 

Chronic  Follicular  Prostatitis. — ^The  operative  steps  in  this  lesion  are 
chiefly  applications  through  the  urethroscope  of  astringents  and  caus- 
tics to  the  mucosa,  the  high-frequency  current  of  Oudin  and  evacua- 
tion by  incision  with  the  long  scalpel  of  individual  acini.  Instillations 
through  long  needles  attached  to  a  hyjDodermic  barrel  may  be  tried. 

The  chief  field  of  operation  is  in  acute  parenchymatous  prostatitis 
having  one  or  more  distinct  abscesses  or  an  old  abscess  either  with 
chronic  discharge  or  frequent  relapses  of  acute  attacks  with  repeated 
rupture  into  the  urethra  or  even  externally. 

The  technic  of  operation  is  simple  for  cases  with  pus  present  to  the 
examining  finger  by  the  enlargement,  tension  or  fluctuation,  or  with 
pus  indicated  by  severe  absorption  closely  simulating  typhoid  fever, 
with  which  they  are  sometimes  confounded  during  the  first  few  days. 
Equipment  is  the  same  as  in  external  urethrotomy  w^ith  a  guide,  and 
the  preparation  of  the  patient  is  that  usual  for  any  major  operation  and 
of  the  field  by  any  recognized  method,  of  which  none  is  better  than 
tincture  of  iodin,  provided  the  scrotum  is  not  thickly  coated.  iVnes- 
thesia  is  by  choice  general  on  account  of  the  uncertainties  of  the  deep 
dissection,  but  may  be  spinal  in  occasional  cases,  and  rarely  local 
because  the  inflammation  makes  the  instillation  so  painful.  Posture 
is  exaggerated  lithotomy  and  general  landmarks  are  the  rectmn  behind, 
base  of  scrotum  in  front,  with  its  raphe,  the  tuberosities  of  the  ischia 
and  the  urethra  made  prominent  by  the  author's  irrigating  sound. 
The  incision  should  leave  the  urethra  intact  and  be  made  over  the 
prominence  of  the  swelling  in  unilateral  cases  and  over  each  swelling 
in  bilateral,  discrete  cases,  exactly  as  in  bilateral  cowperitis  and  over 
the  abscess  as  a  whole  in  bilateral  confluent  cases.  Its  form  may  be 
straight  and  oblique,  horizontal  or  cu^^^ilinear,  as  in  perineal  prosta- 
tectomy. The  horizontalincision  is  to  be  preferred  when  possible 
because  it  most  conserves  the  muscular  structiu-es  of  the  perineum, 
gapes  longest  for  drainage  and  is  in  general  parallel  with  the  prostatic 


126        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

ducts.  Tlie  superficial  field  is  the  perineal  skin,  fat  and  fascia  and 
avoids  the  muscles  as  far  as  possible  hy  blunt  dissection  to  the  lower 
surface  of  the  gland,  which  is  the  deej)  fiekl.  If  pus  is  not  apparent  to 
the  fiJiger  an  aspirating  needle  will  locate  it,  upon  which  as  a  guide 
the  straight  l)la(le  sharp  point  bistoury  is  entered  and  the  prostate 
divided  to  the  limit  of  the  skin  incision.  The  finger  in  the  wound  now 
explores  the  cavity  of  the  gland  for  other  foci  and  gently  breaks  them 
into  the  main  pocket.  The  rouniled  tip  of  a  velvet  eye  catheter  is 
passed  into  the  wound  for  irrigation  and  stitched  to  the  skin  for 
drainage  combined  with  one  or  more  cigarette  drains  which  with 
external  dressing  and  a  good  T-binder  still  all  hemorrhage.  No  suture 
of  the  wound  should  be  necessary.  If  no  pus  is  located  free  incision  is 
warranted  as  a  relief  of  hyperemia  and  absorption.  Pus  will  ai)pear 
in  such  a  wound  (piite  regularly  after  a  day  or  two. 

The  disa])pro\ed  methods  are  puncture  of  the  abscess,  with  trocar 
and  cannula,  through  either  the  perineum  or  the  rectum,  because 
neither  route  nor  instrument  gives  adequate  drainage,  and  the  rectum 
becomes  infected  with  the  gonococcus  and  the  abscess,  with  the  flora 
of  the  bowel,  notably  the  Bacillus  coli  communis. 

Immediate  Ajtertreatment. — Irrigation  of  the  bladder  is  adx'isable 
through  the  author's  tunneled  and  grooved  sound,  used  as  a  guide 
before  its  removal,  and  observation  and  change  of  the  dressing  for 
imdue  drainage  or  oozing,  and  remote  aftercare  is  removal  of  the 
drainage  tube  in  from  three  to  five  days  and  of  the  cigarette  drains 
in  from  five  to  ten  days  when  the  patient  begins  to  get  up.  Standard 
nursing  and  diet  are  the  rule.  When  the  wound  has  practically  healed, 
cautious  attention  to  the  posterior  urethritis  should  be  begun  and  ])rose- 
cuted  with  great  judgment  in  order  not  to  offend  the  recovering  gland 
again. 

Cure. — Cure  is  not  possible  for  entire  restitution  in  the  pathological 
sense,  but  relief  from  all  symptoms  and  restoration  to  nearly  normal 
physiology  is  usual  in  the  symptomatic  aspect.  Return  of  the  urethral 
mucosa  to  absolute  normal  probably  rarely  occurs.  Perhaps  most 
important  of  all  is  relief  from  infectiousness  in  })otii  the  follicular  and 
the  pa^ench^Tnatous  forms,  thus  constituting  bacteriological  cure — a 
most  important  sociologic  matter,  because  the  prostate  is  copiously 
and  directly  related  with  the  production  of  the  semen. 

SEMINAL  VESICULITIS  OR  SPERMATOCYSTITIS. 

Occurrence. — Infection  or  affection  of  the  seminal  vesicles  as  a 
complication  of  any  urethral  condition  is  a  rare  occurrence  except  in 
posterior  suppurative  and  especially  posterior  gonococcal  urethritis, 
of  which  the  latter  is  taken  as  the  type. 

Etiology. — It  may  appear  during  acute  disease  or  during  an  exacer- 
bation of  chronic  disease  or  simply  in  the  course  of  the  latter,  induced 
by  an  exciting  cause.  Seminal  vesiculitis  has  as  exciting  causes  direct 
extention  of  infection  by  the  gonococcus  from  a  posterior  urethritis 


SEMINAL  VESICULITIS  on  SPERMAl'OC'YSTiriS  127 

through  the  ejaculatory  ducts  as  they  emerge  through  the  collicuhis 
seminahs  nearly  at  the  midpoint  of  the  prostatic  urethra.  The  pre- 
disposing causes  are  lowered  local  resistance  through  other  forms  of 
urethritis,  notably  catarrhal  and  diathetic  lesions,  through  congestion 
of  masturbation  and  venereal  and  dietetic  excess,  and  tlirough  infiaiii- 
mation  augmented  by  traumatism  from  catheters,  sounds,  urethro- 
scopes, instillations,  irrigations  and  the  like.  The  most  potent  con- 
tributing cause  is  coitus  or  masturbation  during  a  posterior  gonococcal 
chronic  urethritis. 

Varieties. — Seminal  vesiculitis  is  recognized  under  the  following 
forms,  primary  and  secondary  as  to  occurrence;  unilateral  and  bilateral 
as  to  situation;  acute,  subacute  and  chronic  as  to  course;  catarrhal, 
suppurative,  gonococcal  and  tuberculous  and  with  and  without 
occlusion  of  the  ducts,  as  to  pathology.  Chronic  seminal  vesiculitis 
belongs  to  the  general  subject  of  chronic  disease  in  later  chapters  on 
page  318. 

The  primary  seminal  vesiculitis  is  of  very  rare  occurrence,  except  in 
tuberculosis,  with  which  this  work  is  not  directly  concerned  except 
mention  and  differentiation.  On  the  other  hand  the  secondary  seminal 
vesiculitis  is  very  common,  associated  with  and  complicating  posterior 
gonococcal  urethritis.  The  catarrhal  form  and  the  suppurative  form 
are  more  commonly  the  terminal  stage  of  the  gonococcal  condition 
than  essential  lesions.  As  in  all  other  glandular  complications  of  gono- 
coccal origin  the  ducts  may  be  occluded  or  not  leading  respectively 
to  abscess  formation  or  severe  infection,  with  constant  drainage  of  pus 
into  the  urethra.  Any  form  of  sperm atocystitis  may  be  unilateral  or 
bilateral,  with  a  tendency  toward  double  involvement,  wdth  one  vesicle 
the  more  actively  diseased. 

Pathology. —  Acute  Sperviatocystitis. — Acute  spermatocystitis  with- 
out retention  is  in  essence  a  gonococcal  invasion  of  the  seminal 
bladder,  with  a  stage  of  invasion,  establishment  and  termination, 
exactly  as  in  urethritis.  The  cavity  of  the  vesicle  after  the  congestive 
lesions  of  the  invasion  are  over  is  filled  wdth  pus  containing  desqua- 
mated epithelium,  blood,  pus  cells  and  other  detritus.  At  some  points 
the  process  is  deeper  than  elsewhere.  After  temporary  distention  the 
contents  are  evacuated  into  the  urethra  and  the  process  renews  itself. 
The  whole  process  may  be  temporary  or  in  part  permanent,  respectively 
with  full  or  partial  recovery. 

The  pathology  of  acute  spermatocystitis  with  retention  is  that  of  a 
localized  abscess,  more  or  less  destroying  the  seed  sac  as  a  whole  and 
extending  frequently  into  the  surrounding  tissues  and  pointmg  in 
almost  any  direction,  downw^ard  through  the  perineum  to  the  skin, 
forward  into  the  urinary  bladder,  backward  into  the  rectum  and  upward 
into  the  peritoneal  cavity  as  a  rare  occurrence. 

The  pathology  of  chronic  spermatocystitis  depends  on  the  initial 
variety.  If  there  has  been  no  retention  the  chronic  inflammatory 
changes  in  the  gland  and  its  duct  continue  with  persistent  or  relapsing 
discharge.     The  gland  is  often  converted  into  an  indolent  pocket,  in 


128        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

Avliirli  the  discliarge  insistently  forms  and  from  whicli  it  is  evacuated. 
Sometimes  the  ghmd  is  atrojjliied  to  a  eicatrieial  or  infiltrated  recess 
with  little  or  no  discharge. 

If  retention  has  occurred,  the  condition  subsqeuent  to  abscess  any- 
where in  the  body  is  seen,  varying  from  total  destruction  of  the  gland 
to  cyst  formation  and  including  listuhv  into  various  annexa,  as  de- 
scribed under  symptoms.  It  is  in  the  early  periods  of  the  chronic  dis- 
ease that  infectiousness  continues  and  may  last  for  years.  It  is  probable 
that  finally  it  always  disappears  through  Nature's  processes. 

Symiitoms.  Si/)iiptoin^'  of  Acute  Seminal  ]'c.sicNUtis  Withoid  Reten- 
tion.— This  is  the  much  less  severe,  but  the  more  common  form,  and 
its  subjective  symptoms  vary  with  the  activity  of  the  case  and, 
though  relatively  indefinite  in  mild  cases  often  masked  by  the  con- 
comitant i)rostatitis  or  epididymitis,  may  be  in  themselves  very  active. 
They  show,  like  all  infections,  stages  of  invasion,  establishment  and 
termniation  and  local  and  systemic  features.  The  local  subjective 
SNinptoms  of  im-asion  are  insidious,  as  a  rule,  attracting  little  or  no 
attention  in  addition  to  the  symptoms  of  the  condition  with  which  it 
is  comi)licated:  that  is,  posterior  acute  or  chronic  urethritis,  prostatitis, 
funiculitis,  epididymitis  or  epidid\inoorchitis.  Frequently  the  lesion 
is  showTi  only  by  slight  increase  in  s^inptoms  already  existing,  particu- 
larly when  the  primary  condition  is  also  acute.  The  establishment 
shows  sensory,  urinary,  urethral,  rectal  and  sexual  features.  The 
sensory  symptom  is  pain,  dull  or  severe,  thro])bing  or  heavy,  referred 
variously  to  the  deep  pelvis,  neck  of  the  bladder,  root  or  head  of  the 
penis,  testes,  perineum,  anus,  loins,  and  even  kidneys.  The  pain  is 
increased  by  muscular  activity  and  pressure  of  a  full  bladder  or  loaded 
rectimi  and  usually  decreased  by  rest. 

The  urinary  s^'mptoms  are  pollakiuria,  dysuria,  tenesmus  and  vesical 
spasm.  The  painful  frequency  of  urination  is  great  by  day  and  night, 
and  the  act  is  painful  and  straining  with  altered  stream,  particularly 
when  the  prostate  is  much  involved.  For  the  latter  reason  also 
tenesmus  and  vesical  spasm  may  be  almost  uncontrollable.  The 
urethral  symptoms  are  usually  a  decrease  in  the  discharge,  exactly  as 
occurs  in  epididymitis,  unless  the  prostate  is  very  actively  inflamed. 
The  posterior  urethral  discharge,  however,  resumes  its  former  character 
when  the  seed  sacs  are  in  the  declining  stage  of  inflammation,  and  if 
bloody  shows  in  terminal  streaks  or  drops.  As  the  spermatocystitis 
progresses  and  evacuates  itself  the  discharge  increases  and  appears  in 
shreds,  strings  and  slugs,  at  times  uniformly  blood-streaked.  Sharp 
colicky  pain  may  accompany  the  discharge  of  the  distended  vesicles, 
through  a  veritable  colic  of  obstruction.  Reliquet'  claims  that  it  may 
be  confused  with  ureteral  and  renal  colic.  Its  origin  is  disturbance  of 
the  spermatic  vesicle  like  that  of  the  urinary  bladder  during  inflam- 
mation. The  rectal  symptoms  are  constipation  from  pressure  and 
strain  and  fear  of  pain  during  defecation  and  tenesmus  and  spasm 

'  Coliques  Spermatiques,  1880. 


SEMINAL  VESICULITIS  OR  SPERM ATOCYSTIT IS  129 

from  nervous  irritation.  The  sexual  symptoms  are  frequent  erections 
and  seminal  emissions,  accompanied  by  blood  and  the  colic  just  spoken 
of,  which  is  a  more  common  cause  of  the  colic  than  draiuaKe  of  the  i)us. 

The  local  objective  symptoms  of  acute  sperm atocystitis  without 
retention  had  best  be  obtahied  on  a  full  bladder.  Definite  knowledge 
of  the  anatomical  position  of  the  parts  is  necessary.  Above  the  pros- 
tate, near  the  angle  of  each  lateral  lobe,  lie  the  common  ejaculatory 
ducts  formed  by  the  confluence  of  the  vas  deferens  with  its  ampulla 
nearest  the  middle  line  with  the  duct  of  the  seminal  vesicle,  most 
laterally  close  to  the  pelvic  wall.  In  the  angle  between  the  ampulla 
and  the  seminal  vesicle  is  the  ureter,  usually  out  of  reach  in  health 
unless  the  examining  finger  is  unusually  long  and  the  })ladder  highly 
distended.  From  without  inward  the  structures  are  therefore  high 
up,  the  seminal  vesicle,  ureter  and  ampulla  and  low  down  the  duct  of 
the  vesicle  and  the  outlet  of  the  ampulla  uniting  into  the  common 
ejaculatory  duct.  In  order  to  reach  the  vesicle  the  finger  should  be 
passed  to  the  angle  of  the  prostate  and  then  as  far  upward  and  out- 
ward to  the  pelvic  M^all  as  possible.    This  manipulation  will  never  fail. 

One  or  both  vesicles  and  invariably  the  one  more  than  the  other  will 
be  found  hot  and  tender,  tense  and  elastic  or  fluctuating.  Even  gentle 
touch  often  causes  sudden  flow  of  the  contents  into  the  urethra,  which 
the  patient  announces.  Urinalysis  shows  all  glasses  filled  with  pus. 
The  author's  seven-glass  test  is  important.  The  first  three  glasses 
from  a  full  bladder  are  accepted  as  reasonably  indicative  of  the  urethral 
contents;  gentle  massage  of  the  vesicles  wiU  be  foHowed  by  great 
increase  in  the  pus  of  the  sixth  and  seventh  glasses,  containing  rather 
clearly  the  separated  pus  of  each  seminal  vesicle.  The  fifth  glass 
contains  the  prostatic  secretion.  A  catheter  carefully  passed  eliminates 
the  bladder  in  the  fourth  glass.  Thus  most  pus  will  be  in  the  first  and 
second  urethral  glasses  and  in  the  sixth  and  seventh  or  seminal  vesicle 
glasses  and  least  pus  in  the  third  glass  in  the  average  case,  unless  the 
prostate  is  greatly  compromised 

Phosphaturia  from  the  constant  leakage  of  semen  into  the  urethra 
is  sometimes  seen,  especially  in  the  first  glass  and  massage  seminal 
vesicle  glasses,  thus  distinguishing  it  as  a  local  and  not  a  renal  phos- 
phaturia. 

These  facts  should  make  a  diagnosis,  but  the  exploratory  needle 
may  be  used — not  advisedly,  except  in  very  skilled  hands.  The  routes 
are  two:  through  the  rectum,  which  is  to  be  condemned  on  accomit 
of  the  danger  of  infection  and  fistula  and  through  the  perineiun,  which 
is  the  safer,  under  the  following  technic :  The  skin  may  be  nicked  with 
a  scalpel  in  the  perinemii  about  one  inch  (3  cm.)  anterolaterally  from 
the  anus,  and  then  with  the  finger  in  the  rectum  as  a  guide,  the  needle 
is  entered  and  directed  upward,  outward  and  slightly  for^'ard,  passing 
the  prostate  along  the  finger,  which  should  be  on  the  lower  part  of  the 
vesicle.  A  specimen  thus  obtained  should  be  microscopically  examined. 

The  microscopic  diagnosis  displays  pus,  detritus,  spermatozoa,  gono- 
cocci  and  its  allies,  and  should  never  be  omitted.    Its  feature  is  paucity 
9 


130        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

of  prostatic  elements,  provided  the  prostate  is  little  or  not  affected 
and  the  vesicles  predominately  or  solely  involved. 

The  systemic,  subjective  and  objective  symptoms  of  acute  spermato- 
cystitis  without  retention  are  similar  to  those  in  prostatitis:  chill  or 
chilliness,  fever  from  100°  to  105°  F.,  malaise,  nausea  and  vomitinji;, 
depression,  prostration  and  loss  of  sleep.  A  feature  of  this  complica- 
tion is  a  tendency  toward  absorption,  leading  especially  to  arthritic 
and  allied  conditions,  so  that  one  might  clinically  say  that  there  are 
two  tj'pes:  cases  with  absorption  and  cases  without  absorption.  The 
fever  is,  moreover,  apt  to  be  of  the  so-called  urinary  or  urethral  type, 
easily  provoked  by  examination  of  the  vesicles,  suddenly  showing  great 
height,  delirium,  anuria  and  prostration.  It  is  therefore  important 
to  proceed  with  the  greatest  possible  gentleness  in  the  objective 
examination. 

The  s^Tuptomatology  of  subacute  spcrmaiocystiiis  without  retention 
duplicates  the  foregoing  description  in  kind  but  much  less  in  degree. 

The  sjTuptom-complex  of  acute  seminal  vesiculitis  with  retention, 
othenvise  called  abscess  of  the  seminal  vesicles,  augments  all  the  fore- 
going conditions  and  adds  the  presence  of  the  abscess  itself,  which 
may  involve  the  seed  sac  alone  or  the  surrounding  structures  also, 
leading  to  more  or  less  total  destruction  of  the  organ  and  penetration 
of  the  pus  as  set  forth  under  the  subject  of  pathology.  Each  such 
sequel  has  its  own  obvious  train  of  symptoms,  due  to  the  pocket,  sinus 
or  fistula  left  behind,  either  seminal,  urinary  or  fecal.  Abscess  of  the 
seminal  vesicle  is  always  the  source  of  the  absorptive  conditions  pre- 
viously spoken  of.  It  has  another  peculiar  feature  in  that  pressure 
of  the  abscess  may  obstruct  the  ureter  and  cause  distinct  s>Tnptoms  of 
colic.  This  is  more  apt  to  be  the  cause  of  renal  colic  than  is  the  drainage 
of  the  seminal  vesicle  contents  spoken  of  by  Reliquet.^ 

The  termination  of  all  forms  of  acute  seminal  vesiculitis  begins 
usually  in  one  or  two  weeks  after  full  establishment.  Recovery  and 
resolution  occur  in  mild  cases,  much  damage  rather  than  little  damage 
is  seen  in  severe  cases  and  total  destruction  in  abscesses  of  the  sacs. 
Both  sides  are  usually  involved,  of  which  one  may  recover  and  the  other 
not  or  both  be  damaged  the  one  more  deeply  than  its  fellow.  The 
burrowing  of  pus  in  abscesses  with  perivesicular  complications  often 
terminates  in  chronic  pockets,  sinuses  and  fistuloe  in  the  ischiorectal 
fossa,  rectima,  bladder  and  perineum.  Semen  is  an  element  in  the 
fistula  no  matter  where  it  empties  and  should  therefore  always  be 
looked  for  in  suspected  cases,  associated  with  urinary  or  fecal  connec- 
tions. Rupture  of  the  abscess  into  the  peritoneum  and  septicemia 
have  been  noted  in  fatal  cases.  INlyositis,  tenosynovitis  and  iirthritis 
and  other  signs  of  absorption  may  also  occur,  and  do  occur  rather  more 
frequently  with  seminal  vesiculitis  than  with  any  other  gonoocccal 
manifestation.  Ureteral  pain,  owing  to  the  relations  between  the  ureter 
and  the  ampulla  of  the  vas  and  the  vesicle  on  each  side  of  it  and  arising 

'  Loc.  cit. 


SEMINAL  VESICULITIS  OR  SPERMATOCYSTITI S  131 

in  the  pressure  and  obstruction  of  the  distention  and  perivesicular 
infiltration,  is  often  a  later  sequel  in  severe  cases. 

Complications.— The  complications  of  acute  seminal  vesiculitis  are 
rather  the  lesions  with  which  it  is  commonly  associated — namely, 
funiculitis,  epididymitis,  orchitis  usually  making  one  and  the  same 
clinical  picture  and  prostatitis  generally  the  condition  to  which  it  is 
secondary.  Intense  funiculitis  may  cause  peritoneal  symptoms  along 
its  course  from  the  base  of  the  bladder  upward,  forward  and  outward 
to  the  deep  abdominal  ring,  and  if  it  were  not  for  the  obvious  local 
infection  appendicitis  might  be  suspected. 

Diagnosis. — ^The  two  general  forms  of  this  lesion  must  be  remembered 
and  distinguished. 

Acute  seminal  vesiculitis  without  retention  implies  a  vicious  antero- 
posterior infection  of  the  urethra,  in  its  history,  with  intense  involve- 
ment of  the  posterior  portion  of  the  tube  and  often  combined  with 
prostatic  and  testicular  lesions,  even  overshadowing  symptoms  from 
the  seed  sacs  themselves.  The  local  subjective  symptoms  are  absent 
or  merge  with  those  of  the  other  sexual  glands,  such  as  the  prostate, 
or  are  otherwise  sensory,  urinary,  sexual  and  rectal  showing  intense 
irritation.  Objectively  are  found  enlargement  of  one  or  both  sacs  and 
signs  of  infection  with  infiltration,  swelling,  pus  formation  and  peri- 
vesicular invasion.  Systemic  symptoms  are  those  of  severe  infection 
at  any  other  point  of  the  body.  Although  at  first  seminal  vesiculitis 
seems  to  give  less  absorption  than  prostatitis,  in  the  end  it  leads  much 
more  frequently  to  arthritis  and  similar  remote  complications.  Irriga- 
tion of  the  urethra  followed  by  massage  of  the  vesicles,  with  careful 
avoidance  of  the  prostate,  develops  characteristic  contents  for  the 
laboratory.  By  repeating  this  test  at  different  sittings  a  specimen 
from  each  sac  may  be  obtained  with  reasonable  distinction  between 
the  two.  Microscopic  features  display  pus,  detritus,  spermatozoa, 
gonococci  and  its  allies.  Its  feature  is  paucity  of  prostatic  elements, 
provided  the  prostate  is  not  massaged  in  securing  the  specimen  and  is 
itself  much  less  involved.  Treatment  of  the  urethritis,  as  in  other 
complications,  tends  to  benefit  this,  but  the  local  measures  of  massage 
and  similar  procedures  have  a  direct  influence.  Direct  treatment  of 
the  vesicles  should  not  be  undertaken  until  the  subacute  stage  has 
long  been  established. 

Acute  seminal  vesiculitis  ivith  retention  is  a  fully  established  abscess 
of  the  seed  sac  and  offers  all  the  intense  forms  and  kinds  of  s^anptoms 
just  described,  but  much  increased.  Rectal  examination  presents  a 
tense  or  fluctuating  mass  and  widespread  perivesiculitis.  If  external 
ruptm^e  has  occurred,  exploration  of  the  sinus  with  the  probe  along  the 
rectal  finger  is  advised  and  final  in  its  proof.  Surgical  evacuation  of 
the  abscess,  as  yet  unruptured  or  after  rupture,  will  reach  the  cavity 
of  the  destroyed  sac  and  dispel  any  doubt  of  the  lesion. 

Differential  Diagnosis. — Differential  diagnosis  respects  tuberculosis 
and  neoplasm  in  the  following  general  terms: 

Tuberculous  differs  from  (jonococcal  spermatocystitis  in  the  history 
of  other  foci,  as  in  the  lungs,  joints,  kidneys  or  urine,  in  the  s\Tnp- 


132        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

tDiiis  of"  ]>us,  loss  coinmon,  ol'  hlood  iiioro  frtHjiU'iit  in  tlu>  oarly  stages, 
and  wasting  nianitVst  in  tlio  later  stages;  in  nioiv  pain  of  nagging  char- 
acter and  in  the  i)resence  of  nodes  and  nodnles  which  are  tender  not 
only  in  the  vesicle  but  in  the  prostate,  ampulla  of  the  vas,  the  ^•as  in 
the  groin  "and  scrotum  and  epidid\inis  on  one  or  both  sides,  in  its 
painful  seminal  emissions  and  in  signs  of  tuberculosis  in  the  bladder 
and  ])osterior  urethra  on  cystoscoi)y  and  urethroscojiy.  The  Ial)ora- 
tory  tliscovers  no  gonococei  on  smear  and  culture  but  the  bacillus  of 
tuberculosis^  verified  by  animal  inoculation.  There  is  no  gonococcal 
complement  fixation  reaction,  but  often  the  tuberculin  reaction.  l*us 
in  the  sj)ecimen  is  often  less  prominent  and  blood  more  prominent. 
Treatment  by  the  standard  methods  of  management  and  suj)])ort 
against  tuberculosis  are  of  avail.  Serotherapy  with  tuberculin  and 
other  bacterins  is  often  of  advantage,  while  open  invasion  of  the 
vesicles  is  undertaken  Avith  caution  because  the  wound  often  becomes 
infected  widely  and  sinuses  which  never  heal  may  result. 

XeojjJasiic  differs  from  f/onococcal  spermafoci/stitis  in  having  a  very 
dubious  history  of  no  infection  with  the  gonococcus  and  no  tubercu- 
losis in  the  kidneys  or  elsewhere  in  the  body;,  in  its  unilateral  situation ; 
in  its  early  indefinite  or  absent  symptoms  of  dragging  and  discomfort, 
of  irregular  bleeding  with  or  without  seminal  emission  or  coitus,  and 
of  tendency  to  painful  erections;  in  its  nodes,  at  first  discrete  then  with 
progressing  infiltration,  with  little  or  no  pus  but  more  blood  on  pres- 
sure, and  finally  with  involvement  of  the  whole  region.  The  author's 
seven-glass  test  will  secure  a  specimen  from  the  diseased  vesicle  in 
glass  seven,  from  which  the  diagnosis  may  be  possible,  provided  tumor 
cells  appear  in  the  exudate.  The  bloody  character  of  the  tubercle 
bacillus  tends  to  show  that  the  disease  is  not  tuberculosis.  Cystoscopy 
is  negati\'e  early,  but  later  the  bladder  is  deformed  by  the  prominence 
of  the  tumor  and  engorgement  of  the  bloodvessels,  and  may  ulcerate 
by  direct  contiguity.  Urethroscopy  in  the  invasion  is  negative,  but 
blood  may  be  discharged  from  the  vesicle-on  pressure,  with  little  pus  at 
first,  then  much,  associated  with  detritus  from  one  side.  The  labora- 
tory rules  out  the  tubercle  bacillus  and  the  gonococcus,  the  tuberculin 
reaction  and  the  gonococcal  complement  fixation  test.  Specimens 
contain  pus,  blood,  detritus,  epithelia  and  sometimes  shreds  of  tissue 
establishing  the  diagnosis.  Treatment  if  done  early  removes  the 
affected  vesicle  and  proves  the  diagnosis,  anatomically  considered;  if 
done  late  the  specimen  taken  does  likewise. 

Calculous  differs  from  (/onococcal  spermatovesiculitis  in  haA^ing  little 
or  no  history  or  one  similar  to  that  of  the  complication  without  reten- 
tion; in  its  symptoms  of  spermatic  colic  on  the  effort  to  evacuate  the 
vesicle  during  orgasm,  emission  or  massage,  due  to  the  temporary 
plugging  of  the  duct  or  moving  of  the  calculus  about  in  its  pocket; 
in  its  pain  milder  but  comparable  to  that  of  bladder  calculus,  situated 
in  or  referred  to  the  testicle  or  penis,  the  rectum  or  perineum  and  the 
sacral  or  lumbar  region;  in  its  dull  discomfort,  instead  of  pain  due  to 
irritation  by  the  stone  and  evoked  by  a  full  rectum  or  bladder  aufl  their 


SEMINAL  VESICULiriS  OR  HPERMATOCYHTJTJH  133 

evacuation  and  by  massage.  Rectal  examination  detects  the  stone 
and  secures  a  specimen  of  the  pus.  Urethroscopy  is  negative  unless 
the  duct  is  inflamed  or  pus  presents  in  the  field  on  pressure.  The 
seven-glass  test  of  the  author  will  show  one  vesicle  (lis(;as("(l  and  the 
other  normal.  'VYm  laboratory  j)roves  the  absence  of  tubercle  bacillus 
and  the  gonococcus,  the  tuberculin  reaction  and  the  gonococcal  fixa- 
tion test,  but  shows  pus  and  blood  cells,  mucus  and  detritus  from  the 
affected  organ.  Treatment  with  hot  sitz  baths  and  rectal  irrigations 
and  medicinal  sedatives  relieve  the  symptoms  as  in  any  other  form, 
while  exposure  of  the  vesicle  and  removal  of  the  stone  finishes  the 
diagnosis. 

Chronic  Seminal  Vesiculitis. — Chronic  seminal  vesiculitis  repeats 
the  story  cf  severe  and  complicated  attacks  in  the  history  of  gono- 
coccal urethritis  or  in  that  of  a  single  intense  attack  without  cure 
but  with  relapses  of  discharge.  The  actuality  of  or  tendency  to 
absorptive  signs  is  almost  essential. 

In  chronic  sijermatocystitis  without  retention  insistent  discomfort  and 
consciousness  of  the  perineal  zone  without  real  pain  is  the  chief  com- 
plaint, adding  variable  frequency  of  urination,  much  discharge  of  pus 
in  clumps,  slugs  and  strings  and  expression  of  semen  and  pus  during 
defecation.  Almost  uncontrolled  sexual  excitement  and  seminal 
emissions  mixed  with  pus  and  blood  are  not  uncommon.  Objectively, 
the  vesicle  on  one  or  both  sides  show^s  enlargement  with  prominence, 
thickening  with  sclerosis  or  thickening  with  bogginess  and  a  free 
flow  of  pus  and  detritus — all  by  rectal  examination.  The  seven- 
glass  test  reveals  the  anterior  urethra  without  much  involvement,  the 
posterior  urethra  with  many  slugs  and  strings  of  pus,  the  bladder  con- 
tents normal,  the  prostatic  glass  without  or  with  elements  from  this 
gland  and  either  or  both  seminal  vesicular  glasses  equally  or  variously 
filled  with  the  products  of  focal  inflammation.  The  difference  between 
these  two  glasses  diagnosticates  the  more  involved  vesicle  and  whether 
or  not  the  prostate  is  much  involved  as  is  frequently  the  case.  Sys- 
temically  there  is  less  intense  disturbance  but  more  absorption  than 
in  acute  lesions,  so  that  arthritic,  myositic,  tenosynovial  and  cardiac 
lesions  are  by  no  means  uncommon. 

"  In  chronic  sijermatocystitis  with  retention  all  the  foregoing  subjective 
and  objective  conditions  are  found  with  the  fact  of  a  true  abscess  in 
or  about  one  or  both  vesicles  added,  which  follows  either  the  chronic 
persistent  course  with  little  or  no  change  or  the  chronic  progressive 
course  with  relapses.  Absorption  furnishes  the  greatest  syndrome 
which  may  sunulate  almost  any  other  disease,  such  as  anemia,  myelitis, 
neuritis  and  neurasthenia.  Cautious  analysis  of  each  case  is  essential. 
Urethroscopy  of  the  deep  uretln-a  in  both  types  of  the  lesion  reveals 
pus  from  the  prostatic  ducts  if  this  gland  is  compromised,  and  pus 
from  the  seminal  ducts  wdiich  may  have  nearly  normal  or  greatly 
inflamed  mouths  in  a  colliculus  covered  with  edema  and  granulations. 
Much  invoh'ement  of  the  posterior  urethra  is  common.  The  finger 
in  the  rectum  readily  expresses  pus  for  a  specimen,  which  in  the  labora- 


134        COMPLICATIOA'S  AND  SEQUELS  OF  ACUTE  URETIIRiriS 

tory  on  smear  and  culture  reveals  the  ii;onococcus,  with  its  allies 
combined  with  sijcrmatozoa  and  epithelia.  The  seven-glass  test  also 
furnishes  desirable  specimens  and  the  gonococcal  complement  fixation 
test  is  the  final  i)c)siti\e  point.  Treatment  by  massage  of  the  vesicles 
by  their  exj)osure  in  the  ojjcn  operation  completes  the  diagnosis. 

Treatment. — Gonococcal  seminal  vesiculitis  has  recently  assumed 
great  importance  in  all  its  aspects.  Its  significance  is  major  because 
spermatocystitis  is  the  most  potent  single  factor  in  the  absorj)tion 
causing  arthritis  and  similar  systemic  invasion. 

rroi)hylaxis  so  far  as  })ossible  avoids  the  causes  enumerated  in  the 
clinical  re\iew  on  page  127,  such  as  ill  health,  attacks  of  catarrhal 
and  diathetic  urethritis,  frequent  congestion  in  venereal  and  dietetic 
excesses  or  in  traumatism  of  instrumentation  and  medication.  Direc- 
tions as  to  sexual  abstinence  from  direct  and  indirect  excitement  or 
mastm'bation  or  intercourse  during  a  chronic  urethritis  are  important 
and  emphatically  so  in  judicious  treatment  of  posterior  acute  or 
chronic  urethritis.  As  the  symptoms  emerge  imperceptibly  from  those 
of  the  posterior  urethritis  abortion  is  not  practicable. 

Curafire  Treatni ent.—Heliei  of  infection  of  the  sperm  sacs  must  be 
guided  by  the  featiu-es  of  each  case.  Thomas  and  Pancoast^  say — 
"Thus  the  following  considerations  arise:  (1)  Is  the  ejaculatory  duct 
strictured  or  obstructed?  (2)  is  the  vas  deferens  strictured?  (3)  is  the 
inflammatory  collection  in  the  seminal  vesicle  loculated?"  and  quote 
Belfield-  and  Aschofi"'^  to  show  that  strictures  do  occur.  Seminal 
vesiculitis  with  occlusion  therefore  forbids  success  to  massage  and 
vasopunctiu'e  or  vasostomy  and  indicates  vesiculotomy. 

Subjective  and  objective  symptoms  are  sensory,  urinary,  lu'ethral, 
rectal  and  sexual  in  their  elements,  locally,  as  presented  in  the  clinical 
data  on  page  130.  They  have  the  general  type  of  irritation  in  the 
acute  lesions  and  of  the  production  of  pus  with  discharge  or  of  the 
production  of  pus  with  retention  in  the  chronic  cases  according  to 
the  patency  or  occlusion  of  the  duct.  Systemically  absor])tion  is  seen 
chiefly  in  the  chronic  form  with  relapses,  due  to  temporary  occlusion 
of  the  duct  and  retention  of  the  pus,  as  relapsing  abscess  and  less 
commonly  when  the  duct  is  not  obstructed  and  drainage  is  more  or  less 
incessant  and  indolent.  Both  forms,  however,  are  often  active  foci 
of  low-grade  systemic  involvement. 

Management  should  tend  to  maintain  resistance  and  bodily  health 
and  to  provide  antisepsis  by  suitable  hygiene  and  other  protection. 
Rest  in  bed  is  imperative  during  the  acute  disease  or  active  exacerba- 
tions of  the  chronic  disease  and  sexually  through  abstinence  from 
intercourse  and  other  excitement  and  the  abolition  of  seminal  emissions 
by  suitable  sedatives.  In  chronic  cases  this  reflex  cannot  l)e  controlled 
except  through  avoidance  of  irritating  food,  drinks  and  the  fondling 

1  Loc.  cit. 

2  Jour.  Am.  Med.  Assn.,  March  15,  1900,  p.  800;  November  22,  1913,  p.  1867;  Surg., 
Gynec.  and  Obst.,  May,  1913,  p.  .569;  November,  1916. 

3  Loc.  cit.,  p.  24. 


SEMINAL   VESfCULiriS  OR,  SPERMArOCVSTITIS  135 

of  women,  but  intercourse  must  be  forbidden — all  on  account  of  the 
hyperemia  which  in  these  subjects  is  l)ad.  Exercise  is  abolished  during 
active  symptoms  and  is  begun  with  walking  in  chronic  cases  and  with 
avoidance  of  agitation  and  vibration  incident  to  cycling,  running, 
automobiling,  railroad-riding  and  the  like.  Diet  and  drink  are  of 
the  fever  and  nephritis  types  in  acute  cases,  and  always  of  light,  non- 
irritating  varieties  in  chronic  lesions.  Alcohol  in  any  form  or  amount 
had  best  be  abandoned. 

In  physical  measures,  overstimulation  or  even  traumatism  in  acute 
cases  forbids  massage,  but  the  failure  of  competent  drainage  and  even 
retention  of  pus  require  it  in  chronic  spermatocystitis  without  or  with 
occlusion  of  the  duct.  The  preferred  method  requires  a  full  bladder, 
insertion  of  the  gloved  and  well-lubricated  index  finger  into  the  rec- 
tum, supported  by  the  hip  for  penetration  (Fig.  22).  The  vesicle  lies 
farthest  out  of  the  three  structures,  which  from  without  inward  and 
above  the  prostate  are  the  seminal  vesicle,  ureter  and  ampulla  of  the 
vas.  The  finger  reaches  the  highest  part  of  the  vesicle,  and  with 
steady,  firm,  gentle  pressure  passes  along  it  from  above  downward 
and  from  without  inward  toward  the  urethra  and  prostate,  where 
the  ejaculatory  ducts  empty.  The  ampulla  of  the  vas  is  felt  for  and 
massaged  in  the  same  way  because  it  is  almost  always  diseased  like- 
wise. Several  minutes  are  given  to  the  massage  of  each  side  and  the 
treatment  is  repeated  once  in  five  to  seven  days  or  oftener  if  well 
borne,  which  implies  no  reaction  in  the  testes,  prostate  or  seminal 
vesicles  themselves.  Such  massage  duplicates  the  action  of  sexual 
intercourse  in  emptying  the  seed  sacs  of  semen  and  of  pus  in  this  dis- 
ease at  regular  intervals,  but  differs  from  coitus  in  its  freedom  from 
congestion  and  excitement. 

The  hydrotherapy,  locally,  requires  all  measures  to  be  stopped  in 
acute  disease,  to  which  rule  irrigation  of  the  bladder  and  retrojection 
of  the  urethra  in  cases  of  acute  retention  of  urine  are  exceptions  exactly 
as  specified  under  prostatitis.  Rectal  irrigations  through  the  double 
current  tubes  or  through  the  prostatic  cooler  are  fully  worth 
while  in  the  active  cases,  and  sitting  baths  and  leeches  may  be  added 
as  potent  decongestants.  General  baths  augment  elimination  and 
may  inhibit  absorption  and  benefit  rheumatic  tendency.  Turkish 
baths  are  best  of  all.  Light  is  a  convenient  excliange  for  the  heat 
of  hydrotherapy  and  for  its  known  actinic  and  penetrating  effects. 
It  is  attractive  because  so  easily  applied  by  the  patient  himself  with 
the  60-candle  power  therapeutic  lamp  several  times  a  day  for  from 
thirty  to  sixty  minutes  at  each  sitting. 

The  electrotherapy,  locally,  is  contraindicated  in  acute  cases,  but 
is  reserved  for  declining  and  chronic  disease  according  to  the  case. 
Diagnosis  of  the  exact  lesion  is  all  important.  Persisting  infection  calls 
for  the  high-degree  vacuum  glass  electrodes  (Fig.  69),  inserted  into 
the  rectum  and  applied  to  the  affected  vesicles  in  turn  and  steadied 
in  a  suitable  holder  against  slipping.  Urethral  treatment  is  of  less 
service.    Attachment  to  the  negative  pole  of  the  standard  multiple- 


136        COMPLICAriOXS  AXD  SEQl'ELS  OF  ACUTE  mETHRITIS 

plato  liiixh-speeil  static  inacliinc  is  made.  The  sj)ark  gap  is  from 
one-halt'  to  one  and  a  half  inches  for  intensity,  five  to  ten  niinntes 
fix  the  duration  and  alternate  days  are  the  frequency.  There  must 
be  no  pain  or  reaction  after  these  treatments  and  the  intervals 
and  the  sittinjis  arc  made  longer  as  the  case  ])rogresses.  In  absent 
infection  the  static  wave  current  is  applied  through  the  metal 
electrodes,  connected  Avith  the  positive  side  of  the  same  static 
machine.  A  spark  gap  from  one  inch  to  six  inches  sets  the  intensity 
within  the  toU'vance  of  the  patient,  twenty  minutes  limit  the  dura- 
tion and  alternate  days  give  the  early  and  longer  intervals  the  later 
fre(iuenc\'  and  the  accepted  interruptions  should  he  readily  counted. 
Electrolysis,  by  which  a  copi)er,  zinc,  aluminum  or  silver  electrode 
insulated  with  shaft  to  protect  the  anterior  urethra  is  passed  into  the 
deep  urethra  and  attached  to  the  positive  galvanic  i)ole,  is  of  moderate 
value  for  the  urethritis.  The  indiii'erent  electrode  is  ajjplied  to  the 
abdomen.  The  current  is  measured  to  from  3  to  5  milliamperes  and 
the  duration  five  to  ten  minutes  and  the  frequency  every  three  to 
five  days.  There  must  be  no  reaction.  Adliesion  or  spasm  about  the 
electrode  retiuires  reversuig  the  i)olarity  until  the  instrument  is  free 
before  withdrawing. 

The  systemic  electrotherapy  duplicates  that  described  under  acute 
urethritis,  and  referred  to  under  prostatitis,  as  of  benefit  to  elimina- 
tion through  the  skin  and  kidneys,  nutrition  through  the  digestion 
and  circulation  and  sedation  through  the  nervous  system. 

^Medicinal  measures  in  the  acute  spermatocystitis  suggest  sedation 
of  circulation,  sensation,  reflex  irritation  and  functional  disturbance 
by  systemic  administration  exactly  as  in  urethritis  itself.  Support 
against  absorption  and  depreciation  of  health  with  the  secondary 
rhemnatic  tendencies  is  aimed  at  in  the  chronic  forms.  The  various 
drugs  and  formulas  aA^ailable  are  the  same  as  those  given  in  previous 
pages  for  acute  and  chronic  urethritis  and  for  other  complications  in 
their  acute  and  chronic  manifestation. 

The  serimitherapy  may  aid  but  is  without  value  in  some  patients. 
The  seriun  in  acute  cases  may  establish  passive  immunity,  while  the 
bacterins  either  hi  the  autogenous,  heterogeneous  or  Van  Cott's^  mixed 
form  will  possibly  induce  active  immunity,  as  described  in  section 
on  this  subject  on  page  520.  Persevering  administration  without  ex- 
citing extreme  negative  i)hase,  and  with  the  aid  of  other  means  of 
treatment,  is  important,  but  gonococcal  laboratory  products  are  not 
as  successful  as,  for  example,  diphtheria  antitoxin. 

The  local  administration  invariably  presents  no  treatment  of  the 
urethritis  until  the  vesiculitis  is  well  along  on  its  decline.  As  in  hydro- 
therajn',  irrigations,  injections,  instillations  and  ai)plications  are  all 
stopped  during  the  acute  symptoms.  ]{etrojections  in  the  presence 
of  acute  retention  may  be  allowed  with  dilute  fluid.  Retention  of  the 
catheter  is  preferable  to  frequent  passing  of  it  for  this  purpose.    In  the 

'  Loc.  cit. 


SEMINAL  VESICULITIS  Oil  SPEUMATOCYSTITIS  137 

chronic  stage,  after  the  seminal  vesicle  has  been  dealt  with  surgically, 
all  the  methods  and  drugs  applicable  to  posterior  chronic  urethritis 
may  be  chosen  with  caution,  judgment  and  gentleness. 

In  nonoperative  surgery  of  acute  periods,  only  during  retention 
of  urine  an  indwelling  catheter  may  l)e  used  for  relief  for  a  jew  days, 
with  lavage  of  the  bladder  several  times  daily,  or  if  not  severe  a  small 
soft-rubber  catheter  may  be  passed  and  irrigation  performed  with  retro- 
jection.  In  the  late  aftertreatment,  after  the  operati(jn,  the  posterior 
urethritis  requires  attention,  but  its  treatment  must  have  no  reactif>n 
but  only  progressive  benefit,  and  should  be  discontinued  at  the  slight- 
est disturbance.  Dilatation  gently  performed  with  the  author's  irri- 
gating sound,  with  flushing  of  the  bladder  and  retrojection,  or  in  the 
same  manner  the  Bangs  instillating  sound  and  the  Kollmann  dilators 
may  be  used.  Gentle  massage  of  the  posterior  urethra  with  a  soft 
catheter  or  flexible  dilator  in  place  is  sometimes  helpful  when  the  case 
is  nearly  well  and  still  has  indolent  symptoms. 

Operative  surgery  provides  the  same  rules  for  urethroscopic  applica- 
tions and  fulgurations  after  the  operation  on  the  vesicles  themselves 
has  ceased  and  the  sac  recovered.  As  in  prostatitis,  these  measures 
are  of  avail  only  for  the  remaining  posterior  urethritis.  They  are  wdth 
effect  only  on  the  surface  and  immediate  underlying  region.  There 
are  four  approved  operations  available:  vasopuncture,  vasostomy, 
and  the  vesiculotomy  of  Fuller  and  of  Squier,  and  one  disapproved 
technic — aspiration  of  the  vesicle  through  the  perineum.  Thomas  and 
Pancoast^  describe  the  first  two  procedures  as  follows : 

Vasopuncture  and  Vasostomy. — Chronic  spermatocystitis,  with  or 
without  drainage,  is  the  proper  selection  of  case  for  benefit  without 
the  dangers  of  radical  operation,  according  to  Thomas  and  Pancoast.^ 
The  instruments  and  supplies  are  scalpel,  scissors,  forceps,  hemostats, 
ligatures,  small  sharp  and  blunt  retractors,  needle  holder,  needles, 
sutures,  drains  and  dressings,  with  a  large  suspensory  bandage,  also 
hypodermic  syringe,  with  the  following  drugs  of  which  Thomas' 
prefers  collargol,  10  per  cent.  The  other  preparations  are  20  per  cent, 
protein  silver,  made  in  the  Hare  Chemical  Laboratory  of  the  University 
of  Pennsylvania;  argyrol,  10  per  cent.;  protargol,  0.5  to  1  per  cent.; 
nitrate  of  silver,  1  to  2  per  cent.  Anesthesia  is  by  local  infiltration 
with  cocain,  1  in  500  watery  solution,  or  its  analogues,  and  the  posture 
is  supine,  with  the  one  landmark  of  the  spine  of  the  pubis  and  the 
cord  passing  outside  and  below  it,  which  places  the  mcision  over  the 
cord  from  one  to  one  and  a  half  inches  long  passing  through  skin  and 
superficial  fascia  as  the  superficial  field  down  to  the  pillars  of  the  super- 
ficial abdominal  ring,  with  the  cord  emerging  as  the  deep  field,  whose 
layers  are  separated  to  reach  the  vas  deferens  usually  behind  and 
above  the  other  structures.  A  rubber-covered  clamp,  after  Crile's 
method,  or  a  stitch  is  passed  across  the  vas  distally  to  prevent  pene- 
tration of  the  drug  into  the  epididymis  and  secondary  chemical  reac- 

1  Loc.  cit.  '  Loc.  cit. 

3  Personal  communication  to  the  author,  April  25,  1916. 


13S        COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

tion.  ^'asopllnctllre  is  pert\)rmocl  by  exposing  the  vas  in  the  inguinal 
canal,  and  then  injecting  through  a  fine  needle  passed  into  its  canal 
various  medications,  and  Aasostoniy  consists  in  Iea\ing  the  vas  open 
for  nunuTous  rei)eated  medications.  During  such  applications  in 
either  of  these  procedures  the  distal  portion  ])assing  to  the  testicle 
should  be  very  gently  closed  with  a  rubber-guar^led  clamp  after  the 
method  of  Crile,  Avhich  will  not  injure  it  if  carefully  performed.  The 
dithculties  of  these  procedures  are  traumatism  to  the  vas  by  repeated 
use  of  the  needle  and  irritation  of  the  mucosa  by  even  dilute  solutions; 
certainly  no  concentrated  medications  could  be  considered.  The  con- 
dition of  the  duct  for  outlet  of  such  fluid  must  also  be  known,  other- 
wise traumatism  of  the  vas  and  vesicle  by  distention  would  be  assured. 
This  detail  is  exactly  like  that  of  injury  to  the  pelvis  and  kidney  by 
overdistention  of  the  ureter  with  fluid  opaque  to  the  .c-rays.  The 
suture  material  is  the  finest  plain  catgut  introduced  transversely  dia- 
metrically across  the  vas  at  about  the  midpoint  of  the  oblique  path  of 
the  needle  puncture.  By  making  sure  to  pick  u})  only  the  outermost 
coat  of  the  vas  there  is  little  danger  of  harm  to  the  hunen,  although 
it  will  be  temporarily  compressed.  This  stitch  seems  to  be  the  only 
effectual  method  of  preventing  backflow  of  the  silver  solution  along 
the  path  of  the  puncture  and  backward  into  the  epidid^iiiis. 

In  ^•asopuncture  the  needle  of  the  syringe  is  gently  passed  into  the 
hmien  of  the  vas  deferens  and  from  3  to  5  c.c.  of  the  solution  gently 
injected,  and  then  the  vas  is  dropped  back  into  place  and  the  Crile 
clamp  remoA-ed  and  wound  closed  with  standard  suture,  with  or  with- 
out a  small  rubber  tissue  drain,  for  twenty-four  hours  against  oozing. 
Primary  union  without  incident  is  the  rule  and  great  pain  in  the  epi- 
didymis and  vesicle  is  the  exception.  One  efficient  injection  relieves 
if  this  method  is  adequate  at  all  in  a  given  case.  In  vasostomy  the 
vas  is  either  slit  longitudinally  or  transversely  divided  and  brought 
into  the  wound  for  repeated  medication  during  from  one  to  four  weeks. 
The  re])air  of  such  an  opening  into  the  vas  is  the  problem  of  this 
technic. 

Aftertreatment. — The  immediate  aftercare  provides  primary  union 
without  drainage  except  for  twenty-four  hours  and  standard  nurs- 
ing and  diet  and  symptomatic  medication  for  vasopuncture,  while 
secondary  union  is  the  rule  for  vasostomy.  Remote  aftertreatment 
respects  the  occasional  chemical  vesiculitis  and  epididymitis  along 
the  lines  already  described  for  them.  Comments  include  the  absence 
of  danger  to  the  seminal  apparatus.  Cautions  avoid  inflammation  of 
the  mucosa  lining  it  by  the  use  of  only  3  to  5  c.c.  gently  injected  and 
the  end-results  are  a  s\Tnptomatic  cure  shown  by  relief  of  sjanptoms 
and  signs,  by  the  absence  of  inflammatory  products  in  the  urethra  in 
the  author's  seven-glass  test  and  perhaps  by  the  presence  or  absence 
of  spermatozoa.  On  the  last  point,  Thomas,  in  a  personal  letter  to 
the  author,  has  no  conclusions  and  likewise  concerning  histopatho- 
logic restoration.  The  author  feels  that  the  difficulties  of  the  pro- 
cedures are  those  of  traumatism  to  the  vas  by  repeated  use  of  the 
needle  and  of  irritation  of  the  mucosa  by  even  dilute  solutions. 


SEMINAL  VESICULITIS  OR  SPERMATOCYSTITIS  139 

Fuller  s^  Vesiculotomy. — Much  credit  is  due  J^'uller,  oi  New  York, 
for  developing  the  surgical  treatment  of  si)ermatocystitis.  Selection  of 
case  respects  all  subacute  and  chronic  conditions  especially  those  with 
systemic  symptoms  and  sequels,  such  as  rheumatism  unrelieved  by 
other  means.  The  instruments  are  few  and  usually  only  scalpel, 
scissors,  long-grooved  director,  needle-holder,  needles,  sutures,  rubber- 
tube  and  cigarette  drains  and  gauze  packing.  Artery  clamps  and 
ligatures  are  rarely  needed  as  the  operation  has  minimal  hemorrhage 
and  retractors  may  be  omitted  because  the  wound  gapes  widely  of 
itself.  The  preparation  of  the  patient  and  the  field  are  the  standard 
used  in  all  major  work  with  special  attention  to  an  empty  bowel  and 
bladder  and  the  anesthesia  is  by  choice  general  although  spinal  might 
be  possibly  used  for  the  posture,  which  is  the  knee-chest  supported  by 
attendants  or  the  strap  and  bar  holders  of  the  ordinary  table.     Super- 


FiG.  26. — Line  of  incision.     (Fuller.) 

ficial  landmarks  are  the  tuberosities  of  the  ischia,  the  borders  of  the 
sacrum,  the  anus  and  the  perineal  body  while  the  deep  landmarks 
as  encountered  are  the  central  perineal  tendon,  rectum,  ischiorectal 
fossa,  urethra  and  posterior  surface  of  the  prostate. 

The  incision  is  transverse  from  tuberosity  to  tuberosity  well  below 
the  anus  and  joined  at  each  end  by  a  6-inch  lateral,  oblique,  liberating 
division  along  the  borders  of  the  sacrum.  All  three  cuts  interest  the 
skin,  superficial  fat  and  fascia  exposing  the  superficial  field,  as  Step 
I,  Fig.  26.  Perineal  dissection  is  Step  II.  Natife-al  retraction  of  the 
wound  releases  the  rectum  for  separation  from  the  prostate  prefer- 
ably with  the  back  and  not  with  the  edge  of  the  knife  in  order  to 
spare  the  muscles  of  the  perineum  and  the  vessels  of  the  rectum  which 
retract  upward  with  the  bowel  while  the  perineal  body  with  the  pros- 
tate retracts  downward,  both  through  normal  elasticity  of  the  tissues. 
The  central  raphe  and  tendon  of  the  perineum  are  divided  as  in  Fig. 

1  Jour.  Am.  Med.  Assn.,  May  4,  1901;  Am.  Jour.  Derm.,  vol.  x,  Xo.  3;  Med.  Rec, 
January  23,  1915;  Tr.  Am.  Urol.  Assn.,  vol.  vi,  p.  274;  Tr.  Am.  Urol.  Assn.,  iii,  p.  44. 


140        COMPLICATIOXS:  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

27.  Tho  Hiiijor  must  be  in  the  rectum  as  a  uuide  for  this  technic. 
Rectal  isolation  is  Stej)  III  involvins;-  its  separation  from  the  prostate, 
seminal  vesicles  and  bladder  in  the  deep  fields.  The  left  finger  is 
in  the  rectum  while  the  ri.yht  works  with  the  j^alm  toward  the  pros- 
tate and  the  tip  curved  to  avoid  injury  to  the  bowel,  which  should 
not  be  entered.     Hands  rcsistinu'  the  lin,m>r  arc  cut  throuiih.     When 


issectiiiii.      I  Fuller.) 


the  rectum  is  thus  freed  the  dissection  is  extended  laterally  to  reach 
the  seminal  ^•esicles  (Fig.  2.S).  Insertion  of  director  is  Step  IV  along 
the  a])ex  of  the  forefinger  of  one  hand  resting  on  the  seminal  vesicle, 
while  the  opposite  hand  passes  the  instrument  and  holds  it  in  place 
while  the  guiding  finger  is  withdrawn  (Fig.  29).  Incision  of  the 
vesicle  is  Step  V.     The  knife,  guided  along  the  director  to  the  sac 


Fig.  2S. — Separation  from  the  rectal  wall.      (Fuller.) 


and  its  belly  i)ressed  against  it  by  the  guide,  makes  an  incision  the 
entire  length  of  the  spermatocyst  through  the  jiosterior  wall  at  least 
and  in  severe  cases  through  the  anterior  wall  also.  Additional  reliev- 
ing incisions  are  placed  in  the  same  way  in  infiltrated  cases  (Fig.  30). 
Packing  with  gauze,  as  Stej)  VI,  is  done  along  the  finger  as  a  guide, 
side  to  side:  that  is,  the  right  finger  directs  it  to  the  right  vesicle  while 


SEMINAL  VESfC'd/JT/S  Oh'  HI'KliM Al'OdYSTITI H 


141 


the  left  hand  does  the  packing,  and  vice  versa,  (Fif^.  'M).  Tiifx-  <h-;iins 
and  sutures  are  Step  VTT  so  that  a  small  rnhher  tu})e  is  in  ai>position 
with  the  depth  of  each  vesicle  and  ])osteri()r  to  the  f^au/.e  drain  enicrg- 
ing  near  the  lateral  angles  of  the  wound  across  the  perineum  (Fig.  o^j. 


Fig.  29. — Placing  the  grooved  director.     (Fuller.) 

The  liberating  incisions  are  now  closed  with  silkworm-gut  sutures 
and  the  gauze  and  tube  drains  are  secured  with  safety  pins  and  the 
latter  with  adhesive  plaster  against  slipping.  A  suitable  T-bandage 
or  diaper  is  placed  over  a  standard  dressing,  which  completes  the 
operation  (Fig.  33). 


Fig.  30.— Passing  the  knife.     (Fuller.) 


Aftertreatment. — Immediate  aftertreatment  evacuates  the  bladder 
and  if  spasm  occurs  use  an  indwelling  catheter  for  a  day  or  two 
with  suitable  lavage  and  the  remote  aftercare  leaves  the  drains  //? 
situ  for  several  davs  as  long  as  thev  remain  clean  and  changes  the 


142        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

dressings  as  often  as  discharge  soils  them.     Irrigation  of  the  wound 
is  usually  not  necessary.     Standard  nursing  and  diet  and  symptomatic 


Fig.  31.— Placing  the  packing.      (Fuller.) 


Fig.  32. — Drainage  tube  and  packing.     (Fuller.) 


Fig.  33. — The  completed  operation.     (Fuller.) 


treatment  suffice.  Attention  to  the  urethritis  is  entirely  abandoned 
until  the  patient  recovers  from  the  operation  and  then  a  thorough 
diagnosis  and  conserv'ative  treatment  shoidd  be  followed. 


SEMINAL  VESICULITIS  OR  SPERMArOCVSTITIS 


143 


Squier's^  Vesiculotomy. — This  technic  is  an  advanpe  on  Fuller's,  in 
permitting  the  work  to  be  done  under  the  eye.  The  type  of  case  is 
the  one  having  predominant  purulence,  relapsing  epididymitis,  chronic 


Fig.  34. — Perineal  skin  incision.     (Squier.j 


Fig.  35. — Skin  flap  retracted,  showing  fossae  on  either  sides  of  median  perineal  tendon 
which  have  been  opened  by  blunt  dissection.     (Squier.) 


1  Cleveland  Med.  Jour.,  December,  1913.      Boston  Med.  and  Surg.  Jour.,  June  11, 
1914;  New  York  Med.  Jour.,  February  20,  1915. 


144        CO}rPLICATI().\S  AM)  SEQUELS  OF  ACUTE  URETHRTTIS 

persistent  or  clironic  relaj)sinti  si)erinjit()cystitis,  pain  and  rheumatism. 
The  ])re])aratii)n  t)f  the  ])atient  and  the  field,  the  choiee  of  anesthesia 
and  the  reeognition  of  superficial  and  deep  hmdmarks  are  the  same 
as  iu  any  otlier  ])erineal  operation  and  the  ])osture  is  hy  clioice  tlie 
exas:;.uerated  hthotomy.  '1  lie  incision  is  the  inverted  l  extending 
from  tuherosity  to  tuberosity  of  the  ischium.  Retraction  of  the 
con\ex  Ha])  downward  exposes  the  sui)erficial  field  containing  the 
central  teiidon  of  the  perineum  and  the  ischial  fossre  on  each  side, 
marking  Stej)  1,  h'ig.  .'U.  ()j)cning  the  fossa'  l)luntl\"  with  scissors  or 
clamj)  comprises  Step  IT,  shown  in  Fig.  oo;  while  digital  dissection  into 
them  after  di\ision  of  the  central  tendon  but  before  di\-ision  of  the 
tendinous  union  between  ]M'ostate  and  rectum  is  Ste]i  III,  Fig.  30, 


Fig.  36. — Median  tendon  divided, 
further  blunt  dissection  of  lateral  fossa;. 
(Squicr.) 


Fig.  37. — Hooking  finficr  around  upijcr 
limit  of  muscular  attachments  between 
urethra  and  rectum.      (Squier.) 


and  further  penetration  reaches  the  deep  field  of  the  operation.  Iso- 
lation of  urethrorectal  muscles  with  the  finge^r  hooked  around  them 
and  by  division  upon  the  finger  along  the  tendinous  part  avoids 
injury  of  the  urethra,  spares  the  rectum  and  reaches  the  apex  of  the 
prostate  in  Step  IV,  Fig.  37.  Isolation  of  rectum  from  the  prostate, 
seminal  vesicles  and  bladder  in  front  and  their  retraction  with  a  .strip 
of  half  hard  metal  H  inches  wide  that  may  be  bent  as  desired  at  any 
length  for  the  depth  of  any  wound  in  various  patients  is  Step  \,  Fig. 
38,  and  involves  recognition  of  the  vesicles  by  touch  and  sight.  Pros- 
tatic traction  b>'  sutures  plassed  near  the  bladder  in  either  angle  and 
by  pulling  toward  the  operator  and  upward  toward  the  scrotum 
(Fig.  39)  reaches  the  fascia  of  Dcsnonvillicr  bulged  by  the  distended 
vesicles  or  matted  with  infiltration  as  Step  M,  in  F'ig.  40.     Vesicular 


SEMINAL  VESICULITIS  OR  SPERM ATOCYSTITIS 


145 


enucleation  by  dissection  of  the  fascia  from  the  sacs,  much  as  the 
peritoneum  is  freed  from  the  bowel,  partially  by  blunt  dissection  and 
partially  by  snipping  until  the  layer  of  cleavage  is  found,  and  all 
adhesions  and  inflammatory  compression  relieved,  makes  Step  ^U, 


Fig.  38. — Proper  line  of 
division  of  urethrarectal 
attachment  close  to  the 
urethra.     (Squier.) 


Fig.  39. — Traction  su- 
tures applied,  at  junction 
of  base  of  prostate  and 
bladder;  posterior  retrac- 
tor in  place.     (Squier.) 


Fig.  40. — Traction  upon 
sutures  exposing  vesicles 
covered  by  fascia  of  Des- 
nonviUier.     (Squier.) 


Fig.  41.  Drainage  is  now  performed  by  free,  single  or  multiple  inci- 
sions of  the  vesicle,  ampulla  of  the  vas  and  any  diverticula  and  a 
small  rubber  tube  is  sutured  into  appropriate  pockets  completing 
Step  VIII,  Figs.  42  and  43.     Closure  is  performed  by  suturing  the 


Fig.  41.— Method  of  di- 
vision of  Desnonvillier 
fascia  so  as  not  to  enter 
the  vesicles.     (Squier.) 


Fig.  42.  —  Wide  exci- 
sion of  covering  of  fascia 
exposes  vesicles  beneath 
lines  of  incisions  and  punc- 
tures into  vesicles.  (Squier.) 


Fig.  43. — Methods  of 
anchoring  the  drainage 
tubes.     (Squier.) 


rectum  to  the  urethra  to  restore  as  nearly  as  possible  their  forrner 
relations  and  then  the  skin  is  united  in  the  standard  manner  leaving 
the  drainage  tubes  at  each  angle  (Fig.  44).    A  standard  dressmg 
10 


146        COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

with  a  T-binder  or  diaper  is  applied,  niakino;  the  final  Step  IX.  The 
cautions  require  as  little  cutting  and  as  little  traumatism  as  possible 
in  the  region  of  the  deep  ])erineal  nuiscles,  vessels  and  nerves.  The 
terminal  branches  of  the  pubic  ner^•es  occupy  the  anterior  portion  of 
the  perineal  triangle  and  their  injury  would  lessen  or  abolish  erection. 
In  general  they  are  in  relation  with  and  run  toward  the  crura  of  the 
penis. 

Afiertrcafmcnt. — The  aftertreatment  is  the  same  as  that  for  any  other 
perineal  operation  both  inunediately  and  remotely  and  duplicates  that 
specified  for  Fuller's  vesiculotomy. 


Fig.  44. — Closure  of  wound,  showing  position  of  tubes  and  gauze  drains.     (Squier.) 

Cure  in  the  pathological  sense  of  restoring  the  seminal  vesicles  to 
their  former  anatomical  and  physiological  state  is  well-nigh  impos- 
sible except  in  the  mildest  cases,  but  the  s\Tnptomatic  relief  followed 
by  virtual  physiological  health  is  very  often  seen.  Bacteriological 
cure  is  in  large  measure  the  most  important  because  the  vesicles  may 
remain  for  many  years  a  source  of  infection  in  intercourse  and  of 
absorption  within  the  individual  so  that  failure  in  this  regard  has  a 
sociologic  standpoint  of  great  importance. 

V esiculedomy  is  still  suh  jvdice  much  as  were  the  various  tubal  and 
ovarian  operations  about  a  generation  ago  when  laparotomy  was  still 
a  new  technic.  The  chief  reason  of  doubt  is  that  it  is  very  apt  to  be 
followed  by  sterility  on  the  side  affected  because  although  the  testicle 
remains,  semen  no  longer  reaches  the  urethra  througli  damage  of  the 
outlet  and  surrounding  tissues.  In  typical  cases,  however,  the  vesicle 
may  be  removed  with  little  or  no  damage  to  the  ampulla  and  the 
vas,  provided  there  is  not  much  perivesiculitis. 


EPIDIDYMITIS,  EPIDIDYMObRCHITIS  AND  FUNICUUTIS. 

Clinical  Importance. — Infection  of  the  testis  and  its  duct,  that  is, 
the  epididjTnis  and  the  vas  deferens,  is  a  complication  of  gonococcal 
disease  of  grave  clinical  importance,  because  it  may  unsex  the  patient 
in  either  or  both  sides.     In  occurrence  it  is  one  of  the  two  most  com- 


EPIDIDYMITIS,  EPIDIDYMOORCHITIS  AND  FUNIC  (JUT  IS     147 

mon  complications;  the  first  is  infection  of  the  small  urethral  mucous 
glands  and  the  second  is  invasion  of  the  vas,  epididymis  and  testicle. 
The  laity  denominate  it  "swollen  testicle,"  or  "big  ball,"  independ- 
ently of  the  varieties  medically  distinguished. 

Classifications. — Varieties  are  recognized  according  to  cause,  occur- 
rence, location  and  course.  According  to  cause,  the  lesion  is  gono- 
coccal or  nongonococcal,  of  which  the  latter  is  rare  and  the  former 
almost  universal  and,  therefore,  accepted  as  the  type  for  description 
and  comparison.  As  to  occurrence  the  infection  is  primary  or  second- 
ary, of  which  the  latter  is  almost  the  unvaried  rule,  in  that  it  is  a 
sequel  of  posterior  acute  or  chronic  urethritis,  prostatitis,  seminal 
vesiculitis  and  the  like  and  in  that  it  rarely  if  ever  is  itself  antecedent 
to  urethral  or  periurethral  conditions,  excepting  alone  tu})erculosis, 
which  does  not  concern  this  work.  As  to  location,  it  is  unilateral  or 
bilateral  and  involves:  (1)  the  epididymis  alone,  which  is  the  com- 
monest form,  either  as  a  whole  or  in  the  globus  major  or  globus 
minor  predominately;  or  (2)  involves  the  epididymis  and  the  testicle, 
which  is  the  less  common  form,  as  a  rule  the  orchitis  being  later  than 
the  epididymitis  and  the  reverse  order  is  hardly  ever  seen;  or  (3) 
involves  the  vas  deferens  as  a  whole  or  in  portions,  especially  near  the 
testicle  and  base  of  the  bladder  in  the  ampulla.  Associated  condi- 
tions which  add  subvarieties  are  vaginalitis  or  acute  hydrocele  and 
seminal  vesiculitis.  Extension  into  the  tunica  vaginalis  from  an  epi- 
didymitis is  in  mild  or  marked  degree  rather  common,  but  extension 
of  an  orchitis  into  a  periorchitis  is  never  seen  as  the  process  is  limited 
by  the  fibrous  tunica  albugiiiea.  Taylor^  says  that  the  more  common 
variety  is  epididymitis  with  adjacent  deferentitis  and  vaginalitis  and 
the  less  common  is  epididymoorchitis  with  vaginalitis.  A  peculiar 
variety  makes  the  epididymitis  antecedent  to  the  sjinptoms  of  ure- 
thritis and  is  explained  by  a  latent  focus  of  virulent  infection  in  the 
posterior  urethra,  excited  by  alcoholic  or  sexual  debauch  and  rapidly 
extending  down  the  vas  into  the  epididymis  and  testicle  and  inhibit- 
ing through  its  activity  the  onset  of  urethral  sjonptoms  exactly  as  it 
checks  them  temporarily  when  the  reverse  order  of  pathogenesis  is 
seen.  In  each  case  it  is  to  be  noted  that  the  urethral  symptoms 
appear  or  reappear  when  the  subsidence  of  the  epididymitis  is  present. 

Etiology. — As  usual  the  causes  are  systemic  and  local,  predisposing 
and  exciting. 

The  systemic  causes  are  chiefly  predisposing,  hardly  ever  excitmg 
and  are  identical  with  the  factors  underlying  all  forms  of  urethritis, 
as  previously  stated  on  page  19.  Low  resistance  to  infectious  diseases 
in  general  is  undoubtedly  the  preeminent  systemic  cause. 

The  local  predisposing  causes  respect  really  the  antecedent  condi- 
tions, particularly  posterior  acute  urethritis,  prostatitis  and  seminal 
vesiculitis.  For  discussion  in  the  Chapter  on  the  Complications  of 
Chronic  Urethritis,  page  150,  is  reserved  acute  epidid\Tnitis  arising 

1  Genito-urinary  and  Venereal  Diseases,  3d  ed.,  p.  114. 


148        COMPLICATIOXS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

diirini;  an  exacerhatioii  of  })c)stcrior  chronic  invthritis,  chronic  ])ros- 
tatitis  and  chronic  seminal  vesiculitis.  In  these,  years  after  apparent 
recovery,  local  injury  of  the  testicle  by  blows  and  falls,  muscular 
strain  or  pressure,  may  cause  an  acute  invohement  of  the  testicle. 
Likewise  by  the  same  factors  an  old  epidid>  initis  apparently  recovered 
may  light  up  in  a  fresh  attack. 

The  local  exciting  factors  are  transmissit)n  of  the  organisms  and 
lowered  local  resistance.  The  organisms  are  most  commonly  the 
gonococcus  alone  and  much  less  frecjuently  with  pyogenic  and  other 
normally  hannless  bacteria  of  the  urethra  which  descend  the  vas 
with  great  ra])idity.  Local  resistance  is  diminished  by  excesses  hi 
diet,  alcohol,  intercourse  and  muscular  action,  especially  such  as  shake 
the  organs:  cycling,  automobiling,  horseback-riding,  railroading, 
running  and  the  like.  Resistance  is  also  affected  by  traumatism  in 
strains,  falls,  blows  and  the  congestion  of  travel,  by  irritation  of  faulty 
instrumentation,  injection,  irrigation  and  instillation  and  of  drugs 
internally  administered,  such  as  the  balsams,  or  locally  applied,  such 
as  the  astringents.  Cases  are  seen  without  assignable  local  exciting 
factor.  One  under  the  writer's  observation  had  prostatitis  and 
bilateral  seminal  vesiculitis,  funiculitis  and  epididymoorchitis  within 
three  weeks  of  his  infection  without  treatment  locally  or  systemically, 
and  without  other  assignable  excitant.  The  resistance  of  this  patient 
to  the  disease  must  have  been  practically  nil. 

The  local  predisposing  and  exciting  causes  of  nongonococcal  acute 
epididymitis  are  as  follows:  The  urethra  is  normally  inhabited  by 
many  nonvirulent  organisms,  which  are  harmless  when  quiescent  in 
health,  but  harmful  when  carried  into  posterior  urethra  and  inocu- 
lated into  the  raw  mucous  membrane  by  improper  instrumentation  and 
treatment  and  when  engrafted  on  a  catarrhal  lU'ethritis  of  any  origin 
whatever.  They  may  then' invade  the  epididymis,  as  after  stricture 
operations,  such  as  dilatation,  divulsion,  internal  and  external  ure- 
throtomy and  prostatic  operations  such  as  suprapubic  and  perineal 
prostatectomy  and  prostatotomy  and  even  occasionally  prostatic 
massage. 

Pathology. — The  manifestations  are  the  same  in  primary  cases  and 
secondary  cases,  so  far  as  the  affected  organ  is,  strictly  speaking,  con- 
cerned. The  essence  of  the  process  is  invasion  of  the  \'as,  epididymis 
and  testicle  usually  by  the  gonococcus  and  much  less  freciuently  by 
other  organisms.  The  epidid,\Tnis  is  invaded  as  a  whole  or  chiefly  in 
the  globus  minor,  where  it  is  a  single  tube  or,  in  globus  major,  where 
it  is  many  tubes,  and  the  testis  is  involved  in  the  seminiferous  tubules 
and  the  vas  throughout  the  whole  or  various  portions  of  its  length, 
notably  in  the  ampulla  near  the  seminal  vesicle  and  in  its  origin  near 
the  globus  minor.  As  in  every  mucosa  elsewhere  the  lesions  are  edema 
and  infiltration,  exfoliation  and  destruction  of  epithelia  and  pus- 
formation.  Even  the  fibrous  framework  of  the  testis,  epididymis  and 
vas  may  be  involved.  The  exudate  is  the  contents,  consisting  of  semen, 
detritus,  pus  and  organisms,  chiefly  gonococci.     Rapid  progress  is 


EPIDIDYMITIS,  EPIDIDYMOORCIUTIS  AND  FUNIC'ULITIS     149 

probably  due  to  the  confinement  of  the  i)ns  })y  the  anatomical  arrange- 
ment, so  that  the  symptoms  are  so  intense  that  one  cannot  distinguish 
the  orchitis  from  the  epididymitis;  but  on  the  other  hand  resolution 
of  the  exudate  is  the  rule  and  abscess-formation  the  exception. 

The  temporary  lesions  predominate  and  are  characterized  by  the 
foregoing  description,  but  i)ermanent  lesions  are  by  no  means  uncom- 
mon. They  are  infiltration,  thickening  and  occlusion  of  the  epididymis, 
especially  in  the  globus  minor,  where  the  single  tube  of  the  vas  is  already 
established  and  less  commonly  in  the  globus  major  where  the  semi- 
niferous tubules  drain  the  testicle  but  are  not  yet  confluent  into  one 
channel.  Similar  results  may  occur  anywhere  in  the  vas  itself.  Rela- 
tive sterility  as  a  common  occurrence  with  even  atrophy  of  the  testis 
as  a  rare  sequel  occurs  especially  when  the  globus  minor  and  vas  are 
occluded,  but  the  multiple  tubes  of  the  globus  major  make  this  result 
less  common  therein  as  some  of  these  tubules  escape  relatively  or 
entirely.  The  associated  lesions  are  products  of  the  epididymitis 
itself,  chiefly  acute  hydrocele  with  the  usual  features  of  exudative 
inflammation,  or  are  parts  of  the  same  general  infection,  particularly 
seminal  vesiculitis,  prostatitis  and  posterior  urethritis,  each  discussed 
under  its  own  subject. 

Seminal  vesiculitis  occurs  in  at  least  two-thirds  or  three-fourths  of 
the  cases,  either  as  the  antecedent  or  as  the  associate  of  the  epididy- 
mitis. Broennum^  secured  gonococci  from  the  vesicles  in  80  per  cent, 
of  his  cases  examined.  Monod  and  Terrillon^  sum  up  the  pathology 
as  follows:  During  the  acute  complication  the  seminiferous  tubules 
become  greatly  swollen,  their  walls  edematous  and  infiltrated  and  their 
epithelium  loses  its  cilia.  The  tubules  may  contain  pus  and  semen 
mixed  and  the  connective  tissue  stroma  in  which  they  lie  becomes 
edematous  and  infiltrated.  Abscess  is  a  rare  formation  because  the 
exudate  gradually  resolves  and  is  absorbed.  Adjacent  parts  often 
involve  the  process  and  the  testis  is  not  frequently  included.  Acute 
hydrocele  through  inflammation  of  the  tunica  vaginalis  is  usual,  as 
emphasized  by  Jacobson^  and  Malassez  and  Terrillon''  found  that  an 
injection  of  1  per  cent,  to  1.2  per  cent,  solution  nitrate  of  sih^er  in  the 
deferens  will  almost  always  set  up  deferentitis  and  epididjonitis.  The 
solution  is  thrown  into  the  inguinal  canal  with  a  syringe  as  near  as 
possible  to  the  deferens. 

Symptoms. — The  clinical  characters  of  epididjonitis  are  described 
in  the  stages  of  invasion,  establishment  and  termination  and  in  sub- 
jective and  objective,  local  and  systemic  manifestations. 

The  stage  of  incubation  and  invasion  is  so  merged  with  the  ante- 
cedents, usually  posterior  urethritis,  as  to  be  masked  by  their  s^Tnptoms. 
The  onset  is  in  primary  cases  between  the  third  and  sixth  week  of 
posterior  acute  urethritis  with  the  fourth  week  as  the  average  in  uni- 

1  Hospital'^tidende,  1907,  No.  46. 

2  Traite  des  maladies  du  testicle  et  de  ses  annexes,  Paris,  18S9. 

3  The  Diseases  of  the  Male  Organs  of  Regeneration,  1893,  p.  255. 
*  Arch,  de  physiol.  norm,  et  pathol.,  1880,  vii,  738. 


150     COMPLICATIOXS  AXD  SEQUELS  OF  ACl'TE  URETHRITIS 

lateral  cases.  In  bilateral  cases,  the  second  testis  following  the  first 
by  about  three  weeks  or  very  rarely  may  accompany  it.  [Secondary 
cases  may  appear  at  any  time  in  the  ordinary  courses  or  durinu'  an 
exacerbation  of  posterior  chronic  urethritis,  ])rostatitis  or  seminal 
vesiculitis.  The  symptoms  of  invasion  are  usually  most  rapid  and 
tend  to  merge  at  once  with  the  establishment,  so  that  it  is  difficult  to 
set  the  i^eriods  ai)art  and  to  distinguish  the  involvement  of  the  testis 
from  that  of  the  ei)idi(lymis.  The  local  subjective  sxinptoms  are  usually 
])romi)t  within  twrnty-four  hours,  but  sometimes  slower  within  two  or 
three  days  of  discomfort  and  incapacity  for  ambidation  of  the  patient. 
There  are  present,  neuralgia,  pain  and  tenderness,  weight,  heat  and 
discomfort.  The  local  objective  signs  are  slight  enlargement,  boggi- 
ness  and  tenderness.  Systemic  symptoms  are  absent  or  trilling  unless 
])ro(luced  by  the  antecedent  conditions. 

The  local  subjecti^'e  symptoms  of  establishment  are  pain  and 
sensitiveness,  enlargement  and  weight,  pollakiiu'ia,  heat,  congestion 
and  edema  in  the  scrotum.  Of  these  the  last  three  are  more  distinctly 
physical  signs.  The  pain  and  sensitiveness  advance  from  dulness  to  sharp 
intensity,  located  at  first  in  the  \'as  and  descending  with  the  process 
into  the  epididymis  and  testicle.  It  may  therefore  first  be  noted  deep 
in  the  pelvis  in  its  intraabdominal  portion  at  the  base  in  the  bladder 
and  seminal  vesicle  or  in  the  extraabdominal  ])ortion  along  the  inguinal 
canal.  It  may  be  referred  to  the  renal  zone,  perhai)s  through  pressure 
on  the  ureter  by  the  inflamed  ampulla  and  seminal  vesicle  or  through 
reflex  influence.  It  is  usually  constant  Avithout  remissions  or  with 
paroxysms  at  night,  and  sometimes  accompanied  by  scalding  bloody 
seminal  emissions  and  always  by  hypersensitiveness,  which  is  the  promi- 
nent s\inptom.  The  pain  and  tenderness  are  increased  by  mction  and 
decreased  by  rest  and  when  the  testicle  follows  the  epididymis  and  the 
vas  as  a  whole  is  involved,  they  are  likewise  greatly  increased.  Symp- 
toms of  local  peritonitis  aroused  from  the  intraabdominal  portion  of 
the  vas  add  their  characteristic  symptoms  and  increase  those  of  the 
epididymitis.  The  early  sense  of  weight  is  quickly  followed  by  enlarge- 
ment at  first  of  the  epididymis,  then  of  the  testicle,  rendering  support 
grateful  to  alleviate  pain  along  the  cord  from  the  dragging.  Pollaki- 
uria  is  often  distinct  from  the  conditions  antecedent  and  from  the 
secondary  congestion  on  the  floor  of  the  bladder  and  about  the  ureter. 
Discharge  regularly  decreases,  sometimes  disappears,  so  far  as  the 
patient's  obserAation  is  concerned. 

The  systemic  subjecti\'e  symptoms  of  the  establishment  are  not 
marked,  as  a  rule,  excepting  in  seA'cre  cases  or  in  virtue  of  the  whole 
process  of  infection,  in  which  the  epididymitis  shares.  They  are,  as  a 
rule,  chill  or  chilliness,  fever  from  100°  to  103°  F.,  hot  skin,  coated 
tongue,  thirst,  anorexia,  nausea,  vomiting  and  constipation,  depression, 
irritability,  ner\"ousness,  headache  and  insomnia. 

The  local  objective  symptoms  of  establishment  are  tenderness, 
enlargement,  heat,  congestion  and  edema,  hydrocele  and  discharge. 
Palpation  shows  extreme  tenderness  along  the  vas  in  its  ampulla 


EPIDIDYMITIS,  EPIDIDYMOORCIIITIS  AND  FUNKJULITIS     151 

through  the  rectum,  along  its  course  through  the  inguinal  canal  and 
down  the  scrotum  to  the  glo})us  minor,  also  in  the  epididymis  as  a 
whole  or  its  tail  or  head  in  particular  and  finally  in  the  testicle.  If 
the  latter  organ  has  escaped,  it  is  relatively  not  tender.  As  a  rule,  the 
acme  of  the  tenderness  is  either  in  the  globus  minor  or  major  of  the 
epididymis.  The  enlargement  may  be  moderate  or  great,  tense,  harrl 
and  tender,  involving  the  epididymis  only  chiefly  in  its  head,  tail  or 
body,  or  the  epididymis  with  the  testicle  and  the  vas  near  its  origin. 
The  largest  swelling  occurs  when  all  three  are  affected  and  hydrocele 
is  added.  The  surface  of  the  enlargement  is  smooth  and  tortuous  and 
not  hard,  angular  and  knotty  as  in  tuberculosis  of  these  parts.  When 
the  epididymis  as  a  whole  is  involved,  it  forms  a  large  swelling  above, 
behind  and  below  the  testicle,  respectively,  through  the  enlargement 
of  its  globus  major,  body  and  globus  minor,  so  that  frequently  the 
sulcus  normally  between  the  two  is  obliterated.  When  the  testicle  is 
involved,  one  mass  of  fist  size  occurs,  while  the  epididymis  alone  is 
like  a  large  thumb  lying  upon  the  gland. 

The  heat,  redness  and  edema  of  the  scrotum  are  rather  moderate  if 
the  epididymis  alone  is  attacked,  but  somewhat  more  apparent  when 
the  testis,  vas  and  tunica  vaginalis  are  involved.  Extreme  cases  show 
dull  redness  and  lividity.  Acute  hydrocele  or  vaginalitis  marks  involve- 
ment of  the  tunica  vaginalis  testis  in  the  process.  The  effusion  may 
be  fluid,  moderate  in  quantity  and  difficult  to  recognize,  or  the  reverse 
with  very  great  swelling,  or  fibrous  and  scanty  with  adhesions.  Marked 
cases  of  hydrocele  usually  appear  with  every  symptom  greatly  increased : 
the  pain  is  unendurable  and  referred  to  the  thighs,  perineum,  sper- 
matic cord,  deep  pelvis  and  even  loins.  The  redness  and  edema  are 
extensive  and  the  subjective  signs  of  infection  unmistakable.  The 
entire  process  may  be  regarded  as  at  its  height  at  this  time.  Frank 
discharge  from  the  urethra  is  greatly  diminished  and  practically 
abolished  during  the  height  of  the  process,  but  there -is  always  suffi- 
cient exudate  in  the  canal  to  permit  smears  and  to  show  in  the  urinary 
test-glasses. 

The  systemic  objective  symptoms  serve  only  to  verify  those  com- 
plained of  by  the  patient.  The  blood  count  corresponds  with  that  of 
pus-processes.    The  urethral  discharge  is  regularly  scanty. 

The  stage  of  termination  begins  in  five  or  ten  daj'^s  in  cases  without 
successful  treatment,  but  in  half  this  time  in  well-managed  cases  and 
persists  from  ten  to  fourteen  days  in  the  average  case,  less  in  milder, 
longer  in  severer  examples.  The  subsidence  of  sjinptoms  is  rather 
rapid  and  more  or  less  in  the  following  order :  Pain,  tenderness,  conges- 
tion and  edema,  hydrocele  with  its  adhesions  and  the  enlargement. 
The  local  and  systemic  subjective  signs  are  very  early  in  changing,  the 
pain  rapidly  lessens,  the  fever  falls,  nervousness  and  indigestion  dis- 
appear and  the  urinary  distm'bances  decrease.  The  local  and  systemic 
objective  symptoms  behave  in  much  the  same  way.  The  discharge 
previously  diminished  slowly  returns,  but  is  usually  changed  in  con- 
sistency and  quantity,  being  slightly  thinner  and  more  copious,  as  a 


152     COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

rule,  owing  to  the  improvement  in  the  antecedent  urethral  condition 
progressing  during  the  subsidence  of  tlie  epi(iidymitis. 

Palpation  is  no  longer  the  source  of  agony.  The  congestion,  heat 
and  edema  of  the  scrotum  vanisli  anil  signs  of  ahsor])tion  of  the  hydro- 
cele occur^  Enlargement  diminishes,  so  that  the  epididymis  is  distinct 
from  the  testis  beyond  the  now  normal  furrow.  Return  of  the  testicle 
itself  to  its  normal  state  under  the  finger  is  earliest  and  most  prompt, 
if  there  are  no  sequels.  Rapid  hivolution  of  the  ei)ididymis  is  rare, 
but  in  the  average  case  requires  weeks,  sometimes  months.  Permanent 
enlargement  as  a  whole  or  in  the  head  or  tail  is  frequently  seen;  as 
previously  stated,  chiefly  in  the  globus  minor  where  the  seminiferous 
tubules  have  already'  become  one  duct  as  the  origin  of  the  vas  deferens, 
which  for  its  first  few  centimeters  may  also  sufter. 

Chronic  Epididymitis. — Relapsing,  subacute  and  chronic  infection 
of  epidid\inis  and  \as  are  common,  lasting  for  years.  Sterility  is  the 
result  of  obstruction  from  the  nodes  and  of  destruction  by  the  chronic 
suppuration.  Destruction  and  atrophy  of  the  testicle  either  from 
suppiu'ation  or  disuse  through  strictured  Aas  are  by  no  means  unknown. 
Acute  epididATiiitis  tends  toward  resolution  if  it  has  no  sequels,  but 
with  sequels  the  outcome  is  different.  The  usual  important  results 
are  the  lesions  of  the  vas  and  epidid\Tnis,  already  spoken  of,  damage  to 
the  testicle  as  a  secreting  organ,  and  the  unusual  sequels  are  abscess, 
cysts  and  atrophy  of  it,  chronic  hydrocele,  gangrene  of  the  scrotum, 
neuritis,  neuralgia  and  finally  septicemia  and  death. 

Relapsing  acute  epididymitis  during  the  subacute  or  subsiding 
stage  is  another  form  of  termination.  Its  frequent  attacks  upon 
the  delicate  lining  of  the  parts  render  it  likely  to  cause  abscess  of 
the  testicle  or  epidid\Tnis. 

The  outcome  of  gonococcal  acute  epididjinitis  relates  to  life  and  the 
organs  involved.  As  to  life,  the  result  is  good,  as  fatalities  rarely  occur. 
Septicemia  is  rare  and  is  probably  more  the  outcome  of  the  general 
infection  present  than  of  the  epididjinitis  itself.  As  to  the  organs 
involved,  the  outlook  depends  on  management  and  treatment  of  the 
cause  and  of  the  lesion,  on  cooperation  bj''  the  patient  and  on  the 
tendency  toward  relapses.  Without  removal  of  the  cause  and  proper 
care  of  the  epididATnis  and  testicle  progress  of  the  disease  in  the  present 
and  relapses  in  the  future  are  invited.  Without  intelligent  cooperation 
and  a  normal  resistance  to  disease  on  the  part  of  the  patient,  the  end 
result  is  far  less  favorable.  In  the  testicle  absolute  pathologic  restora- 
tion probably  never  occiu-s  in  that  certain  tubules  must  remain  per- 
manently damaged  from  the  nature  of  the  infection,  but  such  damage 
may  be  so  slight  as  not  to  interfere  with  its  function  and  hence  cases  of 
clinical  restoration  are  the  rule.  In  the  epididymis  absolute  recovery 
seems  likewise  very  rare,  owing  to  the  penetration  of  the  disease  into 
the  fibrous  wall  of  the  canal,  whence  proceed  thickenings  which  always 
remain  but  clinical  recovery,  however,  is  common.  Only  infiltrations 
with  occlusion  are  important.  As  previously  stated,  foci  of  disease 
in  the  globus  major  are  less  occluding  than  in  the  globus  minor.    Ster- 


EPIDIDYMITIS,  EPlDfDYMOORCIIITfS  AND  FUNIC  HUT  IS     ]o3 

ility  by  occlusion  may  affect  one  testicle  only  witl)r)iit  jiinitin^^  iiii|>rc<,'- 
nating  power  in  the  other  gland,  })ut  sterility  on  both  sifl(;s  remlers 
the  victim  childless  but  does  not  affect  sexual  desire  or  gratification. 
In  domestic  relations,  therefore,  a  childless  marriage  may  arise  from 
these  facts,  which  must  be  settled  before  the  wife  is  held  responsible 
and  perhaps  subjected  to  operative  treatment. 

Diagnosis. — After  a  urethritis  of  rapidly  extending  anteropfjsterior 
type,  great  severity  and  usually  other  complications,  such  as  prostatitis, 
seminal  vesiculitis  and  then  extension  into  the  groin  as  a  funiculitis, 
in  its  history,  the  invasion  of  the  testis  begins.  The  element  of  funi- 
culitis is  invariably  present.  Direct  and  indirect  trauma,  exertion  or 
excesses  may  be  admitted.  Symptoms  are  pain,  tenderness,  enlarge- 
ment, weight,  congestion,  edema,  all  due  to  the  testicular  and  other 
complications,  pollakiuria  proceeding  from  the  posterior  urethritis 
and  urethrocystitis,  temporary  cessation  of  the  urethral  discharge 
from  transfer  of  the  active  process  to  another  organ  and  finally  chill, 
fever  and  similar  signs  of  septic  absorption.  Physical  examination 
reveals  tenderness,  enlargement,  heat,  congestion,  edema,  hydrocele 
and  discharge  as  the  final  index  of  the  cause.  Laboratory  work  is 
devoted  to  smear  and  culture  of  the  urethral  discharge  for  the  gono- 
coccus,  which  while  decreased  is  still  frant  in  amount.  Treatment  of 
the  urethritis  indirectly  benefits  the  testicular  condition  and  when  the 
recovery  period  is  present  and  urethroscopy  of  the  posterior  urethra 
safe,  conditions  there  leading  to  the  epididymitis  may  easily  be  recog- 
nized. 

Differential  Diagnosis  of  Gonococcal  Acute  Epididymitis.^ — Under  this 
subject  are  considered  undescended  and  anomalous  testis,  erysipelas 
of  the  scrotum,  traumatic  orchitis,  traumatic  hydrocele,  tuberculous 
epidid}Tiiitis,  syphilitic  epididymitis,  neoplastic  epididymitis  and 
hernia. 

Acute  epididymitis  in  undescended  and  anomalous  testis  is  often 
difficult  to  settle.  The  gland  must  be  accessible  in  the  inguinal  canal 
or  the  superficial  ring  in  nondescent.  The  epididjuiis  may  be  attached 
above,  before  or  below  the  testicle  through  anatomical  defect,  torsion 
of  the  cord  or  adhesions  within  the  tunica  vaginalis.  All  may  be 
determined  by  the  careful  finger.  The  history  will  show^  an  old  or 
recent  urethral  infection  and  an  acute  painful  course  and  the  laboratory 
by  smear  or  culture  isolate  the  gonococcus.  Rest  in  bed  with  its 
prompt  results  is  an  aid. 

Erysipelas  of  the  scrotum  differs  from  gonococcal  acute  epididymitis 
in  its  severe  general  involvement,  rapid  advance  over  the  scrotiun, 
fiery  redness,  marginate  brawny  infiltration,  absence  of  testicidar 
symptoms  and  signs  of  urethral  discharge,  bacteriology  and  comple- 
ment fixation  test. 

Traumatic  orchitis  and  traumatic  hydrocele  differ  from  gonococcal 
acute  epididymitis  in  the  history  of  definite  injiu-y,  vers'  sudden  onset, 
absence  of  funiculitis  and  of  urethral  findings  and  blood  test.  The 
light  test  is  negative,  but  tension  or  fluctuation  suggests  fluid  and 


154    COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 


Fig.  45. — Hydrocele  of  the  cord.      The  sac  was  nonadherent  and  was  readily  removed 

whole.     (Author's  case.) 


Fig.  4G. — Acute  tuberculous  epididymoorchitis.     Extensive  involvement  of  the 
epididymis  and  testis  is  shown.     (Author's  case.) 


EPIDIDYMITIS,  EPIDIDYMOORCIIITIH  AND  FUNICULITIS     155 

aspiration  brings  blood.  If  the  traumatic  hydrocele  is  not  a  true 
hematocele  then  the  light  test  is  i)ositive  aiul  tlie  necflh;  evacuates  the 
serum  of  true  hydrocele. 


A  B 

Fig.  47. — Tuberculosis  of  the  deep  urethra.  A  is  the  deep  urethra  of  a  recent  acute 
tuberculosis  of  the  epididymis  in  a  young  man ;  from  one  of  three  dilated  prostatic  ducts 
caseous  pus  exudes;  B  is  advanced  tuberculosis  of  the  prostate  in  a  patient  having 
tuberculosis  of  the  right  kidney  and  its  ureter.     (McCarthy. i) 

Tuberculous  differs  from  gonococcal  acute  epididymitis  in  being  a 
chronic  process.  The  history  reveals  tuberculosis  elsewhere  in  the 
body  in  many  cases,  insidious  onset,  little  pain  or  systemic  subjective 
symptoms,  excepting  those  of  the  antecedent  foci  elsewhere.  Some 
cases  show  the  emaciation,  rapid  pulse,  anemia  and  afternoon  tempera- 
ture of  all  tuberculosis.     Examination  shows  a  knotty,  nodular,  fre- 


A  B 

Fig.  48. — ^Tuberculosis  of  the  deep  urethra.  A  represents  extensive  lesions  of  the 
prostatic  urethra  in  a  case  of  tuberculous  epididymitis,  on  account  of  which  operation 
was  refused  and  climatic  treatment  adopted  with  marked  benefit;  B,  advanced  tuber- 
culous foci  of  the  deep  urethra  in  a  patient  with  nocturnal  and  diurnal  frequency  of 
pyuria  and  occluded  left  ureter  due  to  tuberculosis  of  the  kidney.  Focal  necrosis  with 
caseous  destruction  of  the  prostate  on  the  left  and  greatly  dilated  prostatic  diicts  on  the 
right  of  the  colliculus.     (McCarthy .2) 

quently  adherent  epididymis  and  foci  in  the  semmal  vesicles,  prostate, 
lungs  and  the  like.  Bacteriology  of  the  m-ethral  discharge  is  negative 
for  gonococci,  but  if  a  sinus  exists  in  the  testicle,  it  may  be  positive 


1  Surg.,  Gynec.  and  Obst.,  March,  1916,  pp.  330  and  331. 


2  Ibid. 


156     COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

for  tubercle  bacilli.  The  gonococcal  coin])leinent  test  is  negative. 
Tubercle  bacilli  may  be  found  in  the  urine  in  the  mixed  specimen  of 
the  bladder  or  in  separated  specimens  after  ureteral  catheterization. 
The  tuberculin  test  and  tuberculous  management  are  aids. 

Si/philitic  differ^'  from  (/oitucoccal  acute  cpididipititi^'  also  in  being 
chronic.  The  history  of  s\i3hilis  in  primary  and  secondary  manifes- 
tations ma>-  be  given,  as  the  orchitis  is  usuall>-  tertiary.  Physical 
examination  elicits  the  testis  as  first  and  most  and  the  epididymis  as 
second  and  least  involved.  Other  lesions  of  the  tertiary  or  secondary 
stage,  as  the  case  ma>-  be,  are  also  usually  present.  The  swelling  is 
uniform  without  tenderness,  adhesions  or  hydrocele.  Laboratory 
investigation  gives  a  i)ositive  complement  fixation  test  fen*  sy])hilis 
but  negative  for  gonorriiea.  Sometimes  the  Treponema  pallidum  may 
be  obtained  by  asi)iration  of  the  testicle  and  anemia  is  usually  present 
in  neglected  syphilis.  There  are  no  urethral  pus,  gonococci  or  other 
organisms  except  the  normal  urethral  group.  Marvelous  results  of 
intensive  treatment  with  neosalvarsan,  sah'arsan,  mercury  and  the 
iodides  coml)ined  Avitli  hygienic  management  settle  the  ([uestion. 


Fig.  49. — Teratoma  testis,  adult  type.     Patient  well  and  without  secondaries  nearly 
three  years  after  operation.     (Author's  case.) 

Neoplastic  differs  fro)u  gonococcal  acute  epididymitis  in  its  history  of 
slow  onset  followed  by  perhaps  regular  rapid  growth  in  a  few  weeks  or 
months,  absence  of  pain  early,  which  appears,  however,  later.  Anemia 
and  emaciation  and  depreciation  may  be  early  and  marked.  Lym- 
phatic involvement  is  early  and  characteristic.  Teratoma  of  the 
testicle  is  the  most  common  and  rapid  form.  Physical  examination 
shows  a  stony,  hard  testis  and  in  an  advanced  case  the  lymphatic 
channels  and  glands  invaded.  There  is  no  special  tenderness.  The 
testis  is  usually  attacked  first,  then  the  epididymis.  The  laboratory 
findings  are  no  urethral  pus,  no  gonococci  cr  other  organisms  except 
the  normal  urethral  flora,  no  complement  fixation  test  for  cither  gonor- 
rhea or  syphilis.  The  blood  may  show  the  changes  characteristic  of 
malignant  disease. 

Hernia  differs  from  gonococcal  acute  epididymitis  in  its  history  of 
anatomical  defect,  or  acquired  and  slow  onset,  after  direct  or  muscular 


EPIDTDYMITTS,  EPTDTDYMOORCIITriS  AND  FUNJCULITIH     157 

violence  or  during  chronic  cough,  consti})ation,  strain  and  the  like. 
The  pain  is  of  dragging  not  of  intense  incai)acitating  character  and 
without  fever,  chill  or  other  sign  of  infection.  Physical  examination 
reveals  a  mass  in  the  inguinal  canal  or  scrotum,  insensitive,  always 
somewhat  distinguishable  from  the  testicle  and  ei>ididymis,  with 
impulse  on  coughing  and  without  redness  or  edema  of  the  skin.  Kedu- 
cible  hernia  permits  restoration  of  the  mass  into  the  abdomen;  irredu- 
cible breech  shows  partial  or  absent  return  of  the  contents  of  the  sac; 
inflamed  or  incarcerated  hernia  presents  inflammation  at  the  site  of 
previously  irreducible  rupture,  while  strangulation  adds  the  terrible 
elements  of  intestinal  obstruction.  Even  in  the  last  two,  the  diagnosis 
is  easy  and  the  mass  separable  from  the  testicle  in  no  small  number  of 
cases. 

"Differential  Diagnosis  of  Gonococcal  Chronic  Epididymitis." — The  same 
basis  as  in  the  acute  exists — history,  physical  and  laboratory  examina- 
tions for  distinction  between  chronic  epididymitis  and  tuberculosis, 
syphilis  and  neoplasm  of  the  testicle  and  hernia.  The  remarks  given 
under  the  acute  lesion  concerning  the  diagnosis  of  undescended, 
anomalous  and  adherent  testes  need  no  repetition  here. 

Tuberculous  differs  from  chronic  epididymitis  in  the  history  of  other 
tuberculous  foci,  slow  onset,  absence  of  urethritis  and  perhaps  latent 
progress  in  the  testicle,  rather  than  early  subsidence  and  later  per- 
sistence from  an  acute  process.  The  physical  examination  may 
reveal  the  other  foci  and  the  systemic  depreciation.  Nodulation, 
adhesion  of  the  testicle  to  the  skin,  chronic  hydrocele  and  local  abscess 
and  sinus  may  be  present.  Laboratory  and  bacteriologic  examination 
reveals  no  gonococci  in  the  urethral  discharge  and  not  infrequently 
tubercle  bacilli  in  the  urine  and  semen,  for  which  the  guinea-pig  test 
must  often  be  employed.  The  various  tuberculin  tests  are  also 
available  with  caution  as  to  deductions. 

Syphilis  and  neoplasm  of  the  testicle  and  hernia  are  sufficiently  dis- 
tinguished from  chronic  epididymitis  under  its  antecedent  acute  form, 
so  that  further  review  would  be  redundant. 

Treatment. — Gonococcal  epididymitis,  epididymoorchitis  and  funi- 
culitis  in  their  significance  as  complications  damage  the  vas,  epididy- 
mis and  testes  more  or  less  profoundly  or  permanently  and  unilaterally 
or  bilaterally  so  that  relative  sterility  may  result.  The  injmy  may 
be  partial  and  what  is  sociologically  important,  infectiousness  through 
the  semen  may  persist  for  a  long  time. 

Prophylaxis. — Careful  instructions  as  to  care  are  essential  during 
posterior  acute  and  chronic  urethritis.  There  must  be  no  excesses 
by  the  patient  in  diet,  drink  or  sexuality.  Thorough  comprehension 
of  lesions  and  adaptation  of  treatment  are  necessary  on  the  part  of  the 
physician  to  prevent  extension  of  the  infection  from  the  urethra  to 
the  sexual  glands.  The  principle  of  immediate  cessation  of  all  local 
treatment,  such  as  irrigation,  at  the  earliest  sign  of  tenderness  or 
neuralgia  of  either  testis  is  too  little  understood  and  followed.  Special 
avoidance  of  the  predisposing  and  exciting  causes  given  in  the  clinical 


158    COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

section  on  page  147  is  important.  All  attempts  at  abortion  fail  if 
infection  is  incident.  Fnrtlier  ])ro<]:ress  cannot  be  checked  if  tlie  fore- 
going prevention  has  failed  becanse  the  symptoms  arise  indistinguish- 
ably  from  those  of  the  ])osterior  uretliritis. 


■ 

1  III  / 

Fig.  50. — Belle\'Tie  bridge  for  epididymitis.  The  wide  adhesive  plaster,  tongue- 
depressor  supports  and  gauze  pad  are  shown  in  the  upper  half.  The  lower  surface  of  the 
bridge  ready  to  place  appears  in  the  lower  half.     (Author's  model.) 


Fig.  51. — Hayden's  "bridge"  for  an  acutely  inflamed  testicle.     (Hayden.i) 

The  reader  is  referred  to  pages  495  to  497  of  Chapter  IX  on  General 
Principles  of  Treatment  for  data  of  management. 

'  Loc.  cit. 


EPIDIDYMITIS,  EPIDIDYMOORCIIITIS  AND  FUNICULITIS     159 

Curative  Treatment. — All  m(;asures  at  definite  relief  are  referable 
to  the  features  of  each  case.  The  physical  measures  are  of  little 
benefit  until  the  severity  of  the  attack  is  over  and  then  their  service 
is  indirect.  Massage  of  testis  and  epididymis  is  impossible  but  of 
associated  prostatitis  and  seminal  vesiculitis  is  in  the  late  declining 
stage  advisable  in  aiding  the  cessation  of  one  source  of  the  lesions  in 
the  testes  and  their  outlets.  The  uniform  pressure  of  a  rubber  band- 
age belongs  under  this  heading.  It  is  made  of  dentists'  rubber  dam 
cut  in  a  strip  about  two  and  a  half  inches  wide  and  eighteen  inches 
long,  with  a  short  piece  of  adhesive  plaster  attached  to  the  middle  of 
one  end.  The  bandage  is  wound  reasonably  tight  about  the  affected 
testicle  and  secured  by  the  adhesive  plaster,  which  must  be  short 
enough  not  to  interfere  with  elasticity  in  accommodation  of  possible 
increased  swelling.  Hydrotherapy  is  the  ice-bag  locally  applied  to 
the  testis  supported  by  the  bridge  and  protected  by  gauze  or  flannel 
and  to  the  affected  mguinal  canal  for  the  funiculitis.  Hot  poultices 
of  lobelia  and  tobacco  are  said  to  be  soothing  and  sedative.  Irriga- 
tion of  the  rectum  for  the  prostatitis  and  seminal  vesiculitis,  asso- 
ciated, indirectly  benefit  the  testicle,  and  in  the  later  stages  hot  sitting 
baths  decongest  the  entire  region.  Systemically  body  baths  and 
Turkish  baths  aid  in  elimination  of  absorptive  conditions.  The 
application  of  light  during  long  periods  several  times  a  day  by  the 
patient  with  one  of  the  approved  therapeutic  lamps  soothes,  decon- 
gests,  resorbs  and  fm-ther  acts  in  actinic  influence,  especially  in  the 
later  neuralgic  pains  and  vascular  spasm.  The  electrotherapy  is 
important  even  during  the  acute  stage.  In  the  declining  and  termi- 
nal stages,  however,  the  following  modalities  are  indicated:  The 
modality^  is  the  local  application  on  the  epididymis,  testis  and  vas 
deferens  of  a  surface  vacuum  electrode  attached  to  the  negative  pole 
of  the  multiple-plate,  high-speed,  static  electrical  machine  with  the 
positive  pole  grounded.  The  intensity  is  a  spark  gap  of  a  half -inch 
to  one  inch  giving  0.5  to  1  milliamperes  of  current  which  in  duration 
must  remove  all  pain  at  a  given  sitting — usually  in  from  fifteen  to 
thirty  minutes  or  more.  Frequency  is  daily  for  from  seven  to  ten 
days,  producing  an  action  relieving  vascular  spasm  and  inducing 
resorption  and  drainage  through  the  natural  vascular  and  IjTxiphatic 
channel  and  having  a  result,  as  a  rule,  of  the  disappearance  of  the 
enlargement  in  about  ten  days. 

The  medicinal  measures  are  sedatives  for  the  pain,  urinary  anti- 
septics for  the  pus  and  urinary  diluents  and  antacids  for  the  polla- 
kiuria,  circulatory  sedatives  for  the  hyperemia  and  supportives  for  the 
toxic  influence,  if  present,  and  alteratives,  such  as  the  iodide  of  potash, 
for  resorption — all  by  systemic  administration  according  to  indication. 
Of  questionable  value  during  acute  stages  is  serotherapy,  except  in  the 
occasional  patient  benefited  by  the  antigonococcal  serum  for  the  estab- 
lishment of  passive  immunity.    In  the  chronic  periods,  however,  a  few 

1  Modality  is  a  term  used  by  electrotherapeutists  to  denote  the  type  of  current  used. 


160   co^rPLICATroNS  .i.vd  sequels  of  acute  urethritis 

patients  are  greatly  restoretl  by  autogenous  or  lietert)gencous  bacterin, 
especially  of  the  mixed  type,  such  as  Van  Cott's,  when  absorption  is 
present,  chiefly  from  the  associated  jn-ostatitis  and  seminal  vesiculitis. 

The  local  administration  of  any  urethral  treatment  should  be  dis- 
continued during  the  acute  period  but  ointments,  such  as  ichthyol,  in 
10  to  25  peT  cent,  strength  and  guaiacol  in  25  to  50  per  cent,  strength 
are  of  great  service.  Uectal  irrigations  with  the  double  current  tube 
or  the  prostatic  cooler  treat  the  ])eriin-ethral  structures  with  benefit 
to  the  testis.  Only  after  the  ei)itlidymitis  is  nearly  well  should  any 
in-ethral  treatment  be  even  cautiously  begun  and  most  conservatively 
continued.  Chronic  ej^ididymitis  may  be  made  acute  and  relapsing  by 
imjiroper  in^■asion  of  the  jjosterior  urethra.  Therefore,  instillations, 
retrojections,  catheter-and-syringe  irrigations  and  ai)])licati()ns  in  the 
order  named  and  beginning  with  very  mild  Huids  are  the  only  posterior 
urethral  treatments  proper. 

Xonoperative  Surgical  Measures. — If  acute  retention  of  urine  is 
present,  catheterization  is  called  for  and  if  repetition  is  necessary  the 
indwelling  catheter  is  preferred  for  a  day  or  two  with  protective 
lavage  of  the  bladder  and  decongesting  hip-baths.  The  best  dressing 
of  the  testis  is  the  rubber  bandage  described  above.  Adhesive  plaster 
strapping  is  also  recommended  with  the  disadvantage  of  inelastic  resist- 
ance to  possibly  ad\'ancing  enlargement.  After  the  epididymitis  is  cured 
all  the  other  nonoperative  measures  devoted  to  the  posterior  urethra 
become  available,  as  just  mentioned.  If  stricture  is  a  basis  of  the 
lesion  the  author's  irrigating  sound  is  of  special  value  in  combining 
gentle  dilatation  with  retrojection,  but  injections  by  the  patient  are 
hazardous  even  after  the  epidid}-mitis  has  declined. 

The  operative  surgical  measures  are  five:  (1)  Epididymotomy  for 
pus  in  acute  stages;  (2)  Hagner's  transplantation  of  the  vas  in  chronic 
obstruction ;  (3)  prostatotomy  for  pus  as  an  associative  lesion;  (4)  seminal 
vesiculotomy  for  pus  as  a  concomitant  focus;  and  (5)  urethrotomy  for 
stricture  as  an  antecedent  condition. 

Of  these  five  procedures  prostatotomy  is  fully  discussed  under  paren- 
chjinatous  prostatitis  (page  125),  seminal  vesiculotomy  under  sperma- 
tocystitis  (page  139),  with  occlusion  and  urethrotomy  under  stricture 
(page  395),  and  will  therefore  need  no  further  note  here. 

Eindidymotomy  (Hagner's^  operation)  is  available  in  acute  epididy- 
mitis for  evacuation  of  the  pus  when  there  is  much  accumulation 
and  excessive  swelling  in  selection  of  case.  The  operation  is  not 
difficidt  and  requires  as  instruments  and  supplies  scalpel,  tenotome, 
scissors,  forceps,  hemostats,  small  sharp  and  blunt  retractors,  liga- 
tiu-es,  needle-holder,  needles,  sutures,  drains  and  dressings  with  large 
suspensory'  bandage.  The  preparation  of  the  patient  and  field  are 
standard  and  the  anesthesia  is  by  preference  general  on  account  of 
the  sensitiveness  of  the  testis  during  the  manipulation  but  may  be 
local  by  infiltration  of  the  inguinal  branch  of  the  genitocrural  nerve 

1  Tr.  Am.  Assn.  of  Genito-Urinary  Surg.,  1907,  v,  ii,  p.  262.  Ibid.,  p.  37.  Am.  Surg., 
May,  1908.     Med.  Rec,  December  4,  1909.     Ibid.,  August  10,  1907. 


EPIDIDYMITIS,  EPIDIDYMOORCHITIS  AND  FUNICUUTIS     101 

as  it  emerges  from  the  superficial  abdominal  ring.  The  posture  is 
supine  and  the  prominence  of  the  swelling  along  the  epididymis  at  the 
interval  between  it  and  the  testis  is  the  one  landmark,  determining 
the  site,  extent  and  depth  of  the  incision,  which  passes  through  the 
skin  and  dartos  as  the  superficial  field  down  to  the  tunica  vaginalis 
testis  and  after  hemostasis  reaches  the  obvious  point  of  accumulation 
after  free  division  of  the  tunica  to  the  limits  of  the  skin  oj^ening. 
The  testis  is  then  delivered  upon  warm  towels  and  examined.  Mul- 
tiple punctures  with  the  tenotome  are  made  penetrating  the  infiltrated 
fibrous  capsule  and  entering  the  thickened  connective  tissue  beneath 
as  the  deep  field.  As  the  knife  pierces  such  thickenings  marked 
decrease  in  resistance  is  felt  and  free  pus  may  escape  from  any  of  the 
openings,  which  should  be  enlarged  and  gently  probed  toward  the 
pocket,  which  is  safer  than  further  use  of  the  knife,  and  then  gently 
*  massaged  until  empty.  Irrigation  of  each  pocket  in  the  epididymis 
and  of  the  whole  cavity  of  the  tunica  is  then  done  with  1  in  1000 
bichloride  of  mercury  watery  solution  followed  by  normal  salt  solution. 
Light  suture  of  the  tunica  with  catgut  after  restoration  of  the  testis 
to  its  bed  and  drainage  with  a  cigarette  packing  through  the  suture 
line  in  the  tunica  down  to  the  epididymis  followed  by  standard  closure 
of  the  skin  with  silk  and  a  generous  dressing  within  the  large  suspen- 
sory bandage  or  a  T-binder  closes  the  operation. 

Immediate  Aftertreatment. — Packings  secure  drainage  and  avoid  ad- 
hesions as  far  as  possible  and  remote  aftercare  is  devoted  to  antecedent 
and  associated  conditions  within  and  about  the  urethra.  Drainage 
usually  ceases  on  the  fifth  to  the  tenth  day  and  the  frequency  of  dress- 
ings is  correspondingly  decreased.  Accepted  diet  and  medication  are, 
of  course,  the  rule. 

Epididymovasostomy  (Martin's^  operation). — The  following  essen- 
tials are  noted  in  the  careful  selection  of  case  for  reasonable 
chance  of  success.  Sterility  due  to  causes  other  than  obliteration 
of  the  tail  of  the  epididjonis  is  a  contraindication  and  the 
patency  of  the  vas  deferens  from  the  epididymis  to  the  prostatic 
urethra  must  be  demonstrated  by  preliminary  injection  of  pigment 
passed  in  the  urine  or  received  in  massaged  specimens.  A  vaso- 
puncture as  just  described  is,  therefore,  required.  Martin^  says 
further:  "Before  the  operation  is  undertaken  strictures,  posturethral 
lesions  and  chronic  inflammation  of  the  seminal  vesicles  and  vas 
should  be  cured."  He  also  states  that  a  microscopist  should  be  on 
duty  to  show  the  presence  of  spermatozoa  as  a  means  of  prognosis 
and  of  determining  whether  the  anastomosis  shall  be  into  the  epi- 
didymis or  testis.  The  instruments  and  supplies  are  scalpel,  eye  scis- 
sors and  forceps,  hemostats,  ligatures,  small  sharp  and  blunt  retrac- 
tors, eye-needle  holder  and  needles,  fine  silver  wire  or  silk  sutures, 
drains  and  dressings  with  large  suspensory  bandage.    The  prepara- 

1  Tr.  Am.  Assn.   Genito-Urinary  Surg.,   1907,  ii,  32.      Martin,   Carnett,   Le^a  and 
Pennington,  Univ.  Penna.  Med.  Bull.,  1902-3,  xv,  2. 
*  Loc.  cit. 


162     COMPLICATIONS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

tion  of  the  jxitient  and  fiold  are  of  rocognizoil  ty])e  and  anesthesia, 
local  by  infiltration  of  the  genitocrural  ner\'e  or  general  in  nervous 
patients.  The  landmark  is  the  posterior  border  of  the  testis  and 
the  epididymis  for  the  incision  which  crosses  the  skin  and  su])erficial 
fascia  of  the  dartos  as  the  superHeial  field  and  thus  reaches  the  outer 
side  of  the  sexual  gland  and  spares  the  si)erinatic  artery  and  the 
arters'  of  the  \'as,  Avhich  are  pushed  aside  in  the  deep  field.  The  vas 
is  opened  at  the  level  of  the  globus  major  for  about  one  and  a  half 
inches  and  then  an  ellipse  is  cut  out  of  the  head  of  the  ejjididymis 
in  general  corresi)ondence  with  such  incision.  Martin^  believes  it  is 
better  to  cut  the  vas  oblicpiely,  split  it  upward  for  a  (piarter-inch  and 
sew  this  widely  stretched  lumen  to  the  opening  made  either  into  the 
epidid^Tnis,  or  if  spermatozoa  are  not  found  there,  into  the  testicle. 
Immediate  microscopical  examination  should  be  done  to  decide  this 
point.  Four  sutures  of  silver  wire  or  fine  silk  make  this  union,  one 
at  the  upper  and  lower  limits  of  the  woimd  and  one  at  each  side.  After 
this  the  skin  wound  is  stitched  in  the  usual  manner  without  drain, 
unless  a  small  rubber  tissue  wick  is  used  for  twenty-four  hours. 

The  immediate  aftercare  aims  to  secure  primary  union  by  maintaining 
an  evenly  arranged  dressing  under  gentle  pressure  and  the  remote  after- 
treatment  does  not  neglect  examination  for  spermatozoa  which  may 
appear  early  or  late.  The  posterior  urethi'a,  as  stated  in  the  paragraph 
on  selection  of  case  on  page  IGl,  should  be  as  far  as  possible  cured 
before  and  not  after  the  operation.  The  comments  are  .caution  as  to 
traimiatism  of  the  veins  which  leads  to  thrombosis,  pain  and  delay  in 
recovery,  as  to  traiunatism  of  the  arteries  which  may  produce  loss  of 
the  testis,  and  as  to  demonstration  of  living  spermatozoa  and  patency 
of  the  vas  before  selecting  the  point  of  anastomosis  or  completing  the 
operation.  The  dangers  to  life  or  the  testis  are  nil,  if  none  of  the 
above  accidents  happens  and  the  end  results  in  properly  chosen  cases 
are  a  return  of  \Wmg  spermatozoa  within  a  few  days  or  weeks  or 
months. 

Cvre. — Pathologically,  in  the  absolute  sense  cure  is  rare  and  in  only 
mild  cases,  but  in  partial  degree,  is  common  even  when  occlusion  does 
not  occur,  although  infiltration  remains.  There  is  failure  when  occlu- 
sion is  present  and  the  testis  does  not  functionate  except  in  its  systemic 
influence.  Symptom atically  there  should  be  no  pain,  little  or  no 
nodule  in  either  the  globus  major  or  minor  and  no  absence  of  semen 
in  the  author's  seven-glass  test,  which  is  of  special  value  in  such  cases. 
Bacteriologically  there  must  be  no  gonococci  in  the  semen  secured  by 
the  foregoing  test  or  in  a  condom  worn  at  night  to  preserve  a  seminal 
emission. 

2.    Urinary  Forms. 

Significance.— All  urinary  complications  are  major  on  account  of 
the  importance  of  the  structures  imaded  and  of  the  difficulties  of  cure, 

'  Loc.  cit. 


GONOCOCCAL  ACUTE  UliKTflROCYST/T/S  103 

which  often  lead  to  operative  interference.  The  infection  of  a  pos- 
terior urethritis  may  pass  tlie  sphincter  of  the  bladder  and  invade  the 
urinary  organs  in  regular  order  from  below  npwarrl,  causing  urethro- 
cystitis, cystitis,  ureteritis,  pyelitis,  i)yeIonei)hritis,  separately  or 
variously  associated.  Ascent  of  the  organisms  over  the  direct  con- 
tinuity of  surface  is  the  rule  in  these  cases.  Gonococcal  manifestations 
are  again  accepted  and  described  as  the  type. 

Varieties. — Varieties  refer  to  the  bladder  in  urethrocystitis  and 
cystitis,  to  the  ureter  in  ureteritis  and  pyelitis,  and  to  the  kidney  in 
pyelonephritis  and  pyonephrosis,  as  indicated  in  the  clinical  section. 
These  may  all  occur  separately  or  be  variously  or  collectively  associated. 

Etiology. — The  catarrhal  diathesis  producing  a  favorable  soil  and 
low  systemic  resistance  to  disease  permitting  rapid  progress  are  pre- 
disposing conditions.  Direct  extension  of  the  organisms,  most  com- 
monly the  gonococcus  in  pure  or  associated  infection  from  the  posterior 
urethra  into  the  bladder  and  thence  upward,  is  the  exciting  cause. 
The  gonococcus  renews  its  activity  during  an  exacerbation  of  a 
posterior  subacute  or  chronic  urethritis,  or  invades  upward  through 
its  native  virulence  during  an  acute  attack.  Artificial  extension  pro- 
ceeds from  sounds,  urethroscopes,  cystoscopes  and  catheters,  irriga- 
tion of  the  urethra  under  high  pressm-e  and  with  strong  applications, 
all  producing  subacute  or  acute  catarrhal  inflammation  which  imme- 
diately affects  the  gonococcus.  The  author's  irrigation  sounds  are 
of  value  as  preventives  in  that  the  filling  of  the  bladder  with  a  mild 
antiseptic  through  the  channel  of  the  sound  not  only  sterilizes  and 
washes  the  bladder  free  of  any  pus  inadvertently  dragged  into  it  but 
also  cleanses  the  urethra  from  behind  under  Nature's  own  muscular 
adaptation.  These  sounds  are  described  in  Chapter  VII  on  page  370. 
Similar  in  action  is  local  congestion  due  to  exposure  to  cold,  excesses 
in  food,  drink  and  intercourse  and  the  agitation  of  horseback,  bicycle, 
automobile  and  railroad  riding. 

Prophylaxis. — Prophylaxis  in  general  applies  to  the  group  as  a  whole, 
because  if  the  bladder  is  once  invaded  extension  is  apt  to  occur  by  way 
of  the  blood-current,  the  hTiiph-current  and  the  mucosa  in  direct  con- 
tinuity, especially  if  the  ureter  mouths  are  patent.  Urinary  antiseptics 
during  any  sign  of  irritability  are  indicated  to  increase  the  acidity  which 
is  germicidal.  The  s;^Tnptoms  must  not  be  augmented.  iVrtificial  exten- 
sion should  be  guarded  against,  whose  elements  are  detailed  m  the 
clinical  section  with  reference  to  instruments  (page  506).  All  excesses 
in  food,  drink  and  sexuality  should  be  forbidden.  Abortion  is  rarely 
possible  but  suitable  treatment  will  prevent  a  urethrocystitis  from 
extending  to  the  bladder  as  a  whole  and  confine  a  cystitis  withm  the 
viscus  from  reaching  the  ureters  or  kidneys. 

GONOCOCCAL   ACUTE   URETHROCYSTITIS. 

Definition. — As  the  term  indicates,  urethrocystitis  is  infection  of  the 
posterior  urethra  and  bladder,  of  which  the  latter  element  is  limited 


164     COMPLICATJOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

to  the  cervical  portion  in  the  retropubic  and  ureterotrigonal  qua(h*ants, 
particuhirly  the  triiionuni.  From  tiiis  ori,u;in  the  inilannnatiou  may 
cause  a  geuerahzed  cystitis,  which  is  a  subject  in  itseh'. 

Varieties. — Forms  are  seen  primary  and  secondary  in  origin,  acute, 
subacute  and  chronic  in  course;  nongonococcal  and  gonococcal  in 
bacteric^logy.  The  chronic  lesions  lielong  to  their  own  subject  in 
this  work  and  the  nongonococcal  may  in  description  be  merged  with 
the  gonococcal,  which  gives  the  most  severe  type  alone  or  combined 
with  other  organisms,  notably  the  pyogenic  bacteria  and  Bacillus  coJ'i 
communis. 

Pathology. — The  details  given  under  Cystitis  on  i)age  1()7,  to  which 
the  reader  is  referred,  apply  here.  The  sole  exception  is  the  distribution 
which  in  this  case  is  in  the  annexa  of  the  neck  in  the  retropubic  and 
ureterotrigonal  segments. 

Symptoms. — The  condition  is  regularly  secondary  to  antecedent  com- 
plicated or  uncomplicated  posterior  acute  or  chronic  uretiiritis.  Primary 
causes  are  not  seen  excepting  in  tuberculosis  and  neoplasm  and  the 
congenital  deformities,  which  are  treated  under  Cystoscopy  on  pages 
767,  775  and  781 .  The  disease  has  stages  of  infection,  establishment 
and  termination,  of  which  the  invasion  is  so  insidious  and  brief  that  it 
merges  with  the  establishment,  so  that  when  the  ])atient  complains  of 
symptoms  the  objective  proof  of  the  disease  is  already  fixed. 

The  conditions  are  subjective  and  objective,  local  and  systemic. 
The  local  subjecti^'e  symptoms  are  frequency,  tenesmus,  terminal 
pain,  pus  and  blood  and  at  times  retention.  The  frequency  augments 
and  continues  the  same  symptoms  of  the  antecedent  posterior  urethri- 
tis. The  tenesmus  arises  from  the  inflammation  over  the  muscle, 
giving  the  sensation  of  "unfinished  business"  after  urination.  The 
terminal  pain  and  usually  the  bleeding  also  are  due  to  the  pressure  of 
the  sphincter  muscle  upon  the  inflamed  mucosa,  while  the  pus  is  either 
the  last  dregs  in  the  bladder  or  actually  expressed  from  the  mucosa. 
Retention  arises  from  extreme  edema  and  may  require  judicious 
catheterization. 

The  objective  symptoms  are  best  obtained  by  intelligent  use  of  the 
author's  seven-glass  test.  The  anterior  urethral  and  the  control 
anterior  urethral  specimens  in  the  first  and  second  glasses,  respectively, 
indicate  the  lesions  of  this  part  of  the  canal.  The  third  or  posterior 
urethral  glass  develops  the  lesions  there  with  the  aid  of  the  microscope. 
The  passage  of  a  small  rubber  catheter  brings  the  pus,  mucus  and 
detritus,  sedimented  at  the  neck  of  the  bladder,  through  the  urethro- 
cystitis. These  may  be  followed  by  relatively  clear  urine  from  the 
bladder.  Irrigation  of  this  viscus  until  it  is  clean,  followed  by  full 
distention  and  suitable  massage  of  the  prostate  and  the  seminal  vesicles 
each  in  its  turn,  procures  the  prostatic  and  the  right  and  left  vesicular 
glasses  as  the  fifth,  sixth  and  seventh  specimens  and  proves  the  con- 
dition of  these  organs.  Sedimentation  shows  a  thick  layer  of  pus  at 
the  bottom  of  the  glass  followed  by  a  thinner  blood-stained  or  })lood- 
filled   layer,   next  mucopus   and  finall}'  mucus.     Chemical   analysis 


GONOCOCCAL  ACUTE  URETHROCYSTITIS  105 

usually  shows  acid  urine,  sometimes  alkaline  from  })loo(l,  j)uc1(;(j- 
albumin  from  the  pus  and  seroalbumin  from  the  blood  and  luj  easts  or 
other  renal  elements.  Jiaeteriologically  gonococci  may  be  found  in 
smear  and  culture,  very  often  associated  with  other  organisms,  as 
stated,  and  microscopically  are  seen  epithelia  from  the  posterior  urethra 
and  neck  of  the  bladder,  pus,  blood  and  mucus  in  strings  and  slugs. 
When  the  lesion  is  not  overactive  a  cystoscopy  will  reveal  a  localized 
inflammation  in  the  neck  of  the  bladder  and  the  same  observation  may 
be  made  with  the  cystourethroscope  by  penetrating  the  bladder  with 
it  and  exploring  the  neck  and  the  ureterotrigonal  and  retropubic 
segments  as  a  preliminary  of  urethroscopy. 

The  stage  of  termination  is  completed  first  in  the  subjective,  then 
in  the  objective  symptoms.  All  complaints  cease  usually  before  the 
urine  is  free  of  objective  bladder  elements,  especially  squamous  epi- 
thelia, which  may  persist  for  some  time.  The  urethral  discharge,  which 
usually  decreases  during  severe  acute  urethrocystitis,  reappears  when 
the  latter  subsides,  exactly  as  it  does  during  the  acme  and  subsidence 
of  any  other  severe  complication.  A  few  cases  extend  to  all  four 
zones  of  the  bladder — namely,  the  urachal,  retropubic,  ureterotrigonal 
and  the  subperitoneal,  and  then  terminate  as  a  general  cystitis  does 
or  become  chronic  for  life.  A  still  smaller  number  of  urethrocystites 
may  become  chronic  and  without  termination,  and  catarrhal  and  other 
diatheses  may  produce  relapsing  cases  difficult  to  cure. 

Gonococcal  and  Chronic  Subacute  Urethrocystitis. — The  form  of 
subacute  urethrocystitis  is  so  mild  as  to  have  no  subjective  symptoms 
over  and  above  those  of  the  antecedent  urethral  lesions.  Objectively 
the  bladder  findings  are  present,  which  indicates  that  when  a  posterior 
urethritis  is  slightly  atypical,  the  urine  should  be  examined  for  bladder 
epithelium — a  wise  rule  with  every  such  urethritis. 

The  subject  of  gonococcal  chronic  urethrocystitis  is  reserved  for 
Chapter  I\   on  Chronic  Urethritis,  on  page  328. 

Diagnosis. — Rapid  ascent  of  the  gonococcal  infection  through  the 
anterior  urethra  and  into  the  posterior  portion  marks  the  history,  with 
vicious  symptoms  of  involvement  of  the  neck  of  the  bladder,  such 
as  great  functional,  sexual  and  urinary  disturbances.  Both  these 
reflexes  are  stimulated  and  irritated  in  high  degree.  Occasionally 
there  is  a  history  of  instrumentation.  Symptoms  are  frequency  of 
urination,  tenesmus,  terminal  pain,  pus  and  blood,  and  sometimes 
temporary  retention.  Systemically  the  patient  shows  nervous  dis- 
quietude, chills,  fever  and  prostration  with  the  usual  other  traui  of 
symptoms  incident  to  infection  and  absorption.  As  a  rule,  such 
symptoms  are  less  severe  than  in  complications  m  the  prostate,  seminal 
vesicles,  testicles  and  generalized  cystitis.  Physical  examination 
through  the  rectum  on  a  full  bladder  may  show  great  tenderness 
above  the  prostate  around  the  neck  of  the  viscus.  Only  in  the  declin- 
ing stage  may  cystourethroscopy  or  cystoscopy  be  advisedly  attempted. 
The  three-glass  test  will  show  pus  in  all  specimens  and  much  that  is 
thick  and  blood-stained  in  the  last  glass.    The  seven-glass  test  of  the 


106     COMI'LICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

author  may  be  carried  out  with  cautiou  in  uiild  or  subsiding  cases  and 
will  show  in  the  fourth  or  bhulder  glass,  if  dixided  into  two  specimens, 
most  pus  in  the  first  drawn  off  from  the  trigonum  just  as  the  catheter 
enters  the  bladder  and  perhaps  comparati\ely  clear  urine  in  the 
second  flow.  The  prostatic  and  the  two  seminal  vesicular  glasses 
may  be  normal  except  for  the  presence  of  ])us  and  other  elenuMits  from 
the  posterior  urethra.  In  the  lal)()ratt)ry  on  seilimentation,  pus  at 
the  bottom  of  the  glass  is  usuall\'  followed  by  layers  of  bloody  muco- 
pus,  mucopus  alone,  mucus  and  pus  more  t)r  less  separatetl,  depending 
on  tlie  severity  of  the  lesion.  The  microscope  will  show  that  this 
detritus  consists  only  of  bladder  elements  and  excludes  casts  and 
other  renal  factors.  The  amount  of  albumin  in  the  urine  is  little  and 
due  to  the  pus,  in  comparison  with  albmiiin  due  to  nephritis  by  the 
process  of  transudation.  Treatment  by  irrigation  of  the  bladder 
until  cleansed,  followed  by  the  instillation  of  mild  stimulating  antisep- 
tics and  sometimes  even  a])jjlication  to  individual  ])oints  through  the 
cystoiu'cthroscope,  adds  the  final  proof  of  diagnosis.  Attention  to 
the  urethritis  is  also  important  because  it  removes  the  original  source 
of  extension  of  the  disease. 

Treatment. — The  correlation  of  urethrocystitis  and  cystitis  renders 
essential  the  tliscussion  of  their  treatment  under  Cystitis  at  the  end 
of  this  topic  on  page  173. 

CYSTITIS. 

Definition. — Inflammation  of  the  bladder  is  by  definition  cystitis 
when  it  involves  the  mucosa  as  a  whole,  although  it  may  be  more 
severe  at  some  than  at  other  points,  notably  about  the  neck  in  the  ure- 
terotrigonal  and  retropubic  quadrants. 

Varieties, — Classification  respects  primary  and  secondary  as  to  origin, 
acute,  subacute  and  chronic  as  to  course,  mild  ami  superficial,  severe 
and  deep  or  parenchimatous,  intense  and  ulcerated  as  to  degree,  and 
finally  complicated  and  uncomplicated  as  to  added  lesions.  Primary 
cystitis  does  not  concern  the  purpose  of  this  work,  so  that  the  second- 
ary form  with  antecedent  lesions  of  the  lu'ethra  alone  will  be  con- 
sidered. 

Etiology. — As  a  complication  or  sequel  of  posterior  gonococcal  acute 
urethritis,  cystitis  may  occur,  but  relatively  mfrequently,  or  it  may 
arise  in  the  course  or  during  an  exacerbation  of  posterior  gonococcal 
chronic  urethritis.  In  either  case  the  antecedent  is  a  very  severe 
and  usually  complicated  manifestation  of  the  disease.  The  systemic 
and  local,  predisposing  and  exciting  causes  duplicate  those  given  under 
urethrocystitis,  of  which  the  cystitis  may  be  only  a  later  generalization. 
The  essential  exciting  cause  is  the  gonococcus  producing  the  inflam- 
mation taken  as  the  type,  rarely  in  pure,  more  often  in  associated 
culture,  especially  in  the  older  cases  in  which  it  may  be  unpossible 
or  very  difficult  to  find  the  gonococcus  in  direct  proportion  to  the  age 
of  the  case.  The  associated  organisms  are  commonly  the  catarrhal 
and  pyogenic  cocci,  Bacillus  coli  communis  and  Micrococcus  urecB. 


CYSTITIS  167 

Pathology. — In  the  nature  of  the  disease  the  lesions  are  judged  chiefly 
from  cystoseopic  findings  and  are  really  added  to  the  pathology  of  the 
antecedent  urethral  conditions.  The  essence  is  a  gonococcal  invasion 
of  the  bladder  mucosa  as  a  whole,  sometimes  without,  more  frequently 
with  other  organisms,  characterized  by  congestion,  edema,  desquama- 
tion and  infiltration,  pus  and  blood  and,  in  severe  cases,  by  ulceration. 
The  tissues  involved  are  in  mild  cases  the  epithelial  and  subepithelial 
layers,  beyond  which  no  extension  may  occur;  but  in  severe  cases,  the 
bladder  wall  as  a  whole  may  become  more  or  less  diseased,  especially 
in  localized  spots,  forming  ulcers  of  variable  extent  and  depth.  The 
macroscopic  appearance  shows  the  mucous  membrane  red,  raw  and 
thickened,  rough  and  pus-covered,  bleeding  and  ulcerated,  while  the 
microscopic  features  are  the  same  as  in  other  gonococcal  conditions — 
denuded  epithelium,  infiltration  with  small  round  cells  into  the  sub- 
mucosa,  associated,  of  course,  with  the  congestion,  pus,  bleeding  and 
ulceration.  Temporary  lesions  occur  only  in  the  mild  superficial  cases 
and  are  the  least  frequent,  while  much  more  usual  are  the  severe  cases 
with  permanent  lesions,  such  as  hypertrophy,  trabeculations,  saccula- 
tion, contracture  with  deformity  and  scar  of  ulcers.  Persistent,  sub- 
acute or  chronic,  purulent  cystitis  may  also  be  the  outcome.  Compli- 
catmg  lesions  are  ascending  ureteritis,  pyelitis,  pyelonephritis  and 
ulcerations  of  imusual  depth  and  the  antecedent  urethral  disease  with 
their  complications  are  the  only  associated  lesions. 

Symptoms. — Distinction  is  drawn  between  subjective  and  objective, 
local  and  systemic  manifestations  and  between  the  periods  of  invasion, 
establishment  and  termination.  In  general  the  sjaidrome  is  the  same 
as  that  of  urethrocystitis  only  in  more  severe  degree.  The  stage  of 
invasion  is  masked  if  it  occurs  strictly  during  a  posterior  acute  urethri- 
tis; but  may  be  marked  if  instrimiental  infection  of  the  bladder  is 
responsible.  It  is  characterized  chiefly  by  uncontrollable  uneasiness 
and  rapidly  progressing  pollakiuria  and  increasing  pus  in  aU,  especially 
the  last  test-glass.  The  period  of  establishment  has,  as  in  all  mfec- 
tion  in  variable  degree  and  relation,  these  subjective  and  objective 
systemic  symptoms:  chill  or  chilliness,  fever,  malaise,  prostration, 
anorexia,  nausea,  vomiting  and  constipation,  with  willing  confinement 
to  bed.  The  cardinal  symptoms  are  pollakiuria,  tenesmus,  dysuria, 
pain  and  blood  in  the  systemic  subjective  group  and  tenderness, 
pyuria  and  hematuria  in  the  local  objective  group.  The  pollakiuria 
is  every  few  mmutes,  by  day  or  night,  even  up  to  fifty  to  sixty  times 
in  twenty-four  hours  in  extreme  cases  and  thirty  to  forty  times  in 
early  average  cases.  It  is  decreased  by  rest  in  bed,  which  carries  the 
urine  away  from  the  neck  of  the  bladder,  where  its  presence  in  the 
erect  posture  adds  to  this  worry.  The  tenesmus  is  due  to  the  irrita- 
tion of  the  muscle  by  the  infiammation,  so  that  when  the  bladder  is 
empty  the  reflex  effect  of  fulness  is  still  present.  This  s^Tnptom  is 
often  very  hard  to  bear.  The  dysuria  is  usually  due  to  the  edema  at 
the  neck  of  the  bladder  and  in  rare  cases  induces  temporary  retention 
of  urme  or  it  may  be  due  to  the  antecedent  urethritis  with  complicat- 


168     COMFLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

iiig  prostatitis.  Its  degree  may  only  involve  the  changes  in  the  form, 
force  and  trajection  of  the  stream.  The  pain  is  due  to  the  severity 
of  the  inHanunation,  the  congestion  and  jn-essure  on  the  inflamed 
sm-face  by  the  accumulation  of  urine  and  the  muscular  cttort  of  evacu- 
ation, especially  of  the  last  drops.  The  irritation  of  decomposing  urine 
is  also  a  source  of  i)ain.  The  pain  occurs,  therefore,  before,  during 
and  after  lU'ination,  b>'  day  or  by  night,  is  more  or  less  constant  with 
paroxysms,  increased  by  the  erect  posture  and  motion,  decreased  by 
rest  in  bed.  Blood  in  the  urine  may  proceed  from  ruptm'e  of  capil- 
laries, by  severe  turgescence,  by  muscular  action  of  the  bladder  or  by 
ulceration.  It  is  usually  terminal  in  its  appearance  and  spasmodic  in 
its  source  and  not  great  in  quantity,  as  a  rule.  Tenderness  on  palpation 
and  percussion  over  the  bladder  demonstrate  not  the  viscus  which 
is  usually  empty  but  the  reflex  muscular  rigidity  over  any  inflamed 
organ.  The  altered  urethral  discharge  is  noted  as  decreased  during 
the  acme  of  the  cystitis,  and  pyrexia  as  containing  much  pus  and  some 
blood.  The  three-glass  test  gives  the  most  pus  in  the  first  and  third 
and  least  in  the  second  glass.  The  first  glass  brings  away  sedmient 
near  the  neck  of  the  bladder  and  is,  therefore,  usually  very  thick  with 
pus.  The  second  glass  contains  the  i:>us  as  it  is  mixed  uniformly 
with  the  urine,  which  while  abundant  is  not  so  thick  as  m  the  first  and 
third  glasses.  The  third  glass  through  the  terminal  compression  of 
the  bladder  often  contains  the  most  pus  and  almost  always  the  most 
stringy  mucus. 

The  seven-glass  test  of  the  author  is  available  if  the  case  is  not 
a  severe  one,  so  as  not  to  contraindicate  the  use  of  catheters  and  to 
permit  the  passage  of  small  ones.  The  first  or  anterior  urethral  glass 
with  the  second  or  control  anterior  urethral  glass  vary  with  the  degree' 
of  anterior  urethritis  present.  The  third  or  posterior  urethral  glass 
will  have  its  characters  changed  by  the  pus  from  the  bladder  but 
the  microscope  will  often  distinguish  the  presence  of  prostatic  or  other 
posterior  urethral  elements.  The  fourth  or  catheterized  bladder  glass 
will  with  the  first  flush  bring  away  much  stringy  mucus  and  pus  from 
the  floor  of  the  bladder  and  immediately  thereafter  the  more  even 
mixtm^e  of  pus  and  urine  and  the  last  few  drops  will  be  again  thick  and 
stringy.  The  fifth  or  prostatic  glass,  the  sixth  or  right  seminal  vesicle 
glass  and  the  seventh  or  left  seminal  vesicle  glass  are  obtainable 
after  washing  the  bladder  until  it  is  quite  free  of  pus  and  then  by 
massaging  each  of  these  organs  in  turn  for  its  own  specimen.  The 
value  of  these  last  three  glasses  is  in  demonstrating  the  presence  of 
associated  lesions  in  the  prostate  and  the  seminal  vesicles.  Sedimen- 
tation of  the  specimen  of  urine  is  the  same  in  kind  but  greater  in 
degree  as  that  described  under  Urethrocystitis.  Analysis  shows  the 
reaction  acid  or  alkaline  at  first  and  later  alkaline,  always  through 
mixed  infection.  Some  cases  remain  acid  throughout.  The  albumin 
is  nucleoalbumin  of  pus  and  seroalbumin  if  blood  is  a  factor.  These 
are  difl'erential  points.  The  microscope  reveals  in  a  catheterized 
spechnen  abundance  of  bladder  elements,  but  absence  of  urethral  and 


CYSTITIS  169 

renal  elements.  Red  blood  cells  are  pres(!nt  in  (quantity  according  to 
the  hemorrhage  present. 

The  stage  of  termination  leads  to  total  recovery,  relapses  or  chronic 
cystitis.  Full  cure  is  seen  only  in  the  very  mild  sui)crficial  cases,  which 
leave  behind  no  damage  of  clinical  importance.  The  average  case, 
however,  does  show  damage  and  leaves  a  bladder  of  low  resistance  to 
subsequent  infection  and  relapses  of  the  original  infection  which  may 
be  troublesome  for  the  patient  for  years  or  even  life.  Chronic  cystitis 
is  a  very  common  outcome  of  severe  cases  with  deep  damage  and 
ulceration  and  in  patients  with  relatively  poor  systemic  resistance  to 
all  infection.  These  are  the  bladders  showing  contracture,  deformity, 
trabeculation  and  sacculation  and  easy  prey  of  tuberculosis  later  in 
life.  The  acute  stage  of  cystitis  with  intense  suffering  begins  to  sub- 
side in  from  seven  to  ten  days,  while  the  subacute  declining  period 
extends  from  thirty  to  sixty  days.  Even  after  this  caution  by  the 
patient  is  often  necessary.  Early  correct  diagnosis,  prompt  and 
proper  treatment,  full  and  faithful  cooperation  by  the  patient  are  the 
ground  work  of  cure. 

Complications. — Infection  of  the  bladder  may  extend  up  the  ureter, 
on  one  or  both  sides,  causing  the  complications  of  ureteritis,  pyelitis 
and  pyelonephritis.  Such  extension  is  most  common  when  urethral 
obstruction  exists,  as  in  organic  stricture  or  prostatic  disease  upon 
which  acute  gonococcal  infection  has  been  ingrafted  and  thereafter 
has  profoundly  affected  the  bladder. 


Fig.  52. — Gonococcal  acute  cystitis,  showing  universal  redness,  absence  of  blood- 
vessels, great  edema,  loss  of  normal  elasticity  and  gloss,  infiltration  of  the  mucosa  into 
cerebriform  convolutions  and  folds.  A  string  of  exfoliated  epithelium,  mucus  and  pus 
stretches   across   the  field.     (Marion. *) 

Diagnosis. — Full  clinical  explanation  of  acute  cystitis  lies  m  the 
histories  of  direct  extension  from  a  severe  rapidly  advancing  antero- 
posterior urethritis,  of  the  predisposing  catarrhal  diathesis  or  of 
artificial  extension  by  various  instruments  and  irrigations,  for  the 
secondary  cases.  Primary  causes  are  seen  in  the  differential  diagnosis 
as  tuberculosis,   neoplasm,    deformity    of    childbirth    and    calculus. 

'  Marion,  Heitz-Boyer  and  Germain,  Cj'stoscopie  d'Exploration,  1914. 


170     COMPLICATIOXS  A.\D  SEQUELS  OF  ACUTE  URETHRITIS 

The  syinptoins,  systoinically,  are  those  eomnion  for  infoctiou — chills, 
fever,  prostration,  iligesti\t'  disorder,  high  pulse,  aiul  locally  pollaki- 
iiria,  tenesmus,  dysuria,  pain  and  blood,  tenderness  on  palpation 
through  the  bladder  or  rectum.  Objectively  in  the  multiple  glass  tests 
the  bladder  glass  has  most  of  the  jjus  but  all  glasses  have  abundance — 
a  fact  arising  from  final  exi)ression  of  its  contents.  In  the  seven-glass 
test  of  the  author  during  the  stage  of  subsidence,  a  soft  catheter  may 
be  gently  passed  for  the  bladder  glass  which  will  be  shown  to  contain 
all  the  pus  with  the  sole  exception  of  that  irrigated  from  the  urethra. 
In  the  laboratory,  sedimentation  gives  a  thick  layer  at  the  bottom  with 
thiimer  blood  stained  or  blood  filled  layer  next,  then  pus  or  mucopus, 
and  finally  mucus  and  after  a  while  comparati\'ely  clear  urine.  The 
microscope  reveals  bladder  elements,  to  the  exclusion  of  casts  and 
other  renal  elements  and  smear  and  culture  demonstrate  the  gono- 
coccus.  Albumin  is  in  relatively  small  quantities,  thus  distinguishing 
it  from  albuminuria  of  nephritis.  Exploration  of  the  bladder  with  the 
cystoscope  or  cystourethroscope  is  contraindicated  until  the  stage  of 
termination  is  nearly  established.  If  necessary,  in  the  earlier  periods 
the\'  must  be  used  with  great  caution.  Microscopy  shows  bladder 
epithelium,  urethral  epithelimn  antl  fresh  pus  in  the  recent  cases, 
especially  with  pure  infection,  but  deformed  pus  and  epithelia  and 
abundant  phosphates  in  old  cases  commonly  with  mixed  infection. 
It  must  be  borne  in  mind  that  turbidity  of  the  urhie  may  be  due  to 
pus,  carbonates  and  phosphates  as  admiral)lv  shown  and  distinguished 
in  the  following  table  of  Ultzmann.^ 

Table  of  Urinary  Titrbidity  Tests. 

In  pyuria  by  gradually  boiling  the  upper  part  of  the  urine  in  a  test- 
tube  the  turbiditv 


Vanishes. 

Increases. 

Remains  unchanged 

even  after  addition 

of  acetic  acid. 

If  due  to  acid 
urates. 

If  due  to  earthy  phosphates,  carbonates  or  pus 
corpuscles.     Add  one  or  two  drops  of  acetic  acid. 

The      dimming      is 
caused      by      ca- 
tarrhal    secretion 
or  by  bacteria. 

Dimness     van- 
ishes with  evo- 
lution of  gas: 
carbonates 

Dimness     van- 
ishes  Avithout 
evolution      of 
gas:         phos- 
phates 

Dimness      re- 
mains      un- 
changed: pus 

Further  in  the  diagnosis,  treatment  of  the  urethritis  removes  the 
origin  f)f  the  extension  and  is  of  direct  benefit  to  the  cystitis,  but 
standard  methods  of  treating  the  bladder  with  urinary  antiseptics 
internally  and  with  irrigations,  instillations  and  applications  locally 
still  further  demonstrate  the  case. 

I  Vorlesungen  uber  Krankheiten  d.  Ham.,  1892,  p.  3. 


CYSTITIS  171 

Diagnosis. — In  chronic  cystitis  an  acute  attack  rluririg  a  severe 
urethritis  or  direct  instrumental  infection  or  hematogenous  infarct 
is  recorded  by  the  history  or  frequent  attacks,  without  definite  rehef 
but  with  a  more  or  less  incessant  exacerbating  coiKlitif>n.  Other  forms 
show  periods  of  apparent  cure,  then  a  reinfection  with(Mit  known  cause. 
Thus  the  salient  subjective  and  objective  systemic  symptoms  are 
declining  or  absent.  The  subjective  symptoms  are  never  acute  unless 
an  exacerbation  is  present  but  signs  of  absorption  and  a  low-grade 
septic  state  may  be  predominant  with  low  degrees  of  pollakiuria, 
tenesmus,  dysuria,  pain  and  blood  and  objectively  pyuria,  hematuria, 
the  bladder  glass  filled  with  vesical  pus  in  the  seven-glass  test  of  the 
author,  and  the  cystoscopic  and  urethroscopic  findings  are  absolute, 
because  they  eliminate  the  urethra,  prostate  and  seminal  vesicles  as 
sources  of  the  pus.  The  laboratory  reports  abundant  sediment  of 
vesical  origin  in  the  specimen,  discovers  the  gonococcus  on  smear  and 
culture  and  the  positive  complement  fixation  test  in  the  blood.  Treat- 
ment directed  to  the  bladder  alone  in  the  form  of  irrigations,  instilla- 
tions and  applications  or  to  the  urine  through  the  blood  by  urinary 
antiseptics  helps  settle  the  question,  along  with  gonococcal  or  mixed 
bacterins  in  some  cases.  Drainage  of  the  bladder  is  absolute  in  diag- 
nostic and  curative  results. 

Diiferential  Diagnosis. — Differential  diagnosis  rests  on  the  use  of  the 
cystoscope  and  is  fully  discussed  in  the  section  on  Cystitis  in  Chapter 
XIV  on  The  Bladder  (page  770),  which  deals  with  the  distinguishing 
features  of  the  common  varieties — nonsuppurative  and  suppurative, 
membranous,  ulcerative  and  necrotic,  neoplastic,  calcareous,  tuber- 
culous, colon  bacillary  and  finally  regional,  disseminate  and  general. 

Gonococcal  cystitis  must  be  distinguished  from  pym-ia  arising  in 
other  forms  of  vesical  inflammation,  in  posterior  urethritis  below  it  and 
in  the  ureters  and  kidneys  above  it  in  the  various  degrees  of  pyelitis, 
pyelonephritis  and  pyelonephrosis. 

Other  varieties  of  cystitis  to  be  considered  are  suppurative,  tubercu- 
lous, calculous,  neoplastic,  and  diverticular,  all  whose  details  are  set 
forth  under  Cystoscopy  on  page  761,  but  whose  general  features  are 
these  following.  In  their  histories  antecedent  inflammation  of  the 
uretlira  and  its  annexed  sexual  organs  is  absent  so  that  extension  into 
the  bladder  in  continuity  or  infection  through  instriunents  is  excluded. 
Suppurative  cystitis  is  with  difficulty  distinguished  from  gonococcal 
except  with  the  microscope  and  is  the  one  form  which  may  be  secondary 
to  a  suppurative  urethritis.  Tuberculosis  of  the  bladder  is  insidious 
and  prolonged  in  history  and  in  this  respect  is  closely  followed  by 
neoplasm.  Stone  in  the  bladder  is  usually  preceded  by  gravel  and  other 
signs  of  lithiasis.  Diverticulum  may  give  periods  of  comparative  rest 
followed  by  floods  of  pus.  Siinptoms  of  suppurative  disease  almost 
duplicate  those  of  gonococcal  cystitis  while  tubercidosis  is  the  most 
painful  and  hemorrhagic.  Neoplasm  in  general  is  that  of  a  foreign 
body  followed  by  ulceration  and  slough.  Calcidus  shows  the  pain  and 
frequency,  pressiu-e  and  hemorrhage  of  the  stone  and  always  of  the 


172     COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

pus  which  accH)inpanies  it.  A  divert iciihun  may  cause  coustaut 
cystitis  or  while  fiUiiii;;  up  may  for  a  few  hours  permit  rehitively  clear 
uriue.  Ou  examination  throujj:h  the  rectum  the  tenderness  and  infil- 
tration of  tuberculosis  and  neoplasm  and  the  resistance  and  ballotte- 
ment  may  be  elicited.  Cystoscopy  will  hivarialily  distiuifuish  the  five 
conditions  from  eacli  other  even  at  the  first  sittinji;  in  details  ^iven 
in  Chapter  XllI,  from  pages  761  to  80G.  Catheterization  of  the 
ureters  and  a  suspected  diverticulum  will  verify  the  latter.  In  the 
laboratory  all  refinements  of  examination  of  pus,  detritus,  fragments 
and  other  specimens  will  settle  the  question.  Animal  inoculation  is 
sometimes  necessary  in  tuberculosis.  In  the  treatment  final  ])roof  is 
obtainable  in  some  cases  of  uncertainty  as  special  means  directed 
toward  each  bring  results.  Irrigation  and  antiseptics  benefit  suppura- 
tion, while  tuberculosis  and  neoplasm  are  very  intractable,  especially 
the  latter.  Removal  of  the  calculus  and  treatment  of  the  suppuration 
remaining  behind  cure  the  bladder.  Cystotomy  and  remo^'aI  of  the 
diverticulum  alone  avails  in  its  advanced  forms. 

Posterior  urethritis  differs  from  gonococcal  cystitis  in  that  it  precedes 
any  bladder  involvement  in  the  regular  sequence  of  rapidly  ascending 
anterior  urethritis.  Although  many  symptoms  of  cystitis  may  occur, 
the  lesion  may  be  absent.  Those  of  posterior  urethritis  are  always 
much  less  m  degree  and  usually  of  shorter  duration.  Systemic  signs 
are  absent  or  few  and  slight  and  local  conditions,  such  as  pollakiuria, 
tenesmus,  and  dysuria,  persist  for  only  a  few  da^'s.  Pain  and  tenderness 
in  the  bladder  over  the  symphysis  and  through  the  rectum  are  usually 
absent,  likewise  blood  in  the  urine.  The  ordinary  three-glass  test 
shows  pus  in  all  but  most  in  the  first  and  least  in  the  third  which 
reverses  the  findings  in  cystitis  and  the  seven-glass  test  of  the  author 
always  gi\'es  the  bladder  glass  by  catheter  clear,  but  such  specimen 
should  be  taken  only  in  the  declining  period.  In  the  laboratory  the 
microscope  will  sho^w  only  posterior  urethral  elements  with  none  or 
very  few  bladder  signs.  If  complications  in  the  prostate  and  vesicles 
are  present  then  specimens  from  these  sources  will  also  be  there. 

Pyelitis,  Pyelonephritis  and  Pyonephrosis  Differ  from  Cystitis. — 
Unless  careful  analysis  of  each  case  is  made  pus  found  in  the  bladder 
will  be  regarded  as  originating  there  instead  of  in  the  kidney  or  ureters. 
In  the  history,  cystitis  gives  no  element  of  diathesis  or  low  resistance, 
previous  inflammation  or  other  conditions  leading  to  the  kidneys  in 
the  primary  cases.  In  the  secondary  or  ascending  cases  which  follow 
a  cystitis,  this  record  is  reversed.  In  the  symptoms,  subjectively, 
during  distention  and  evacuation  the  bladder  gives  pain  and  distress 
in  its  own  zone  of  the  body  above  the  symphysis  and  in  the  perineal 
and  anal  regions,  at  times  with  the  urethra.  Renal  pyuria  is  either 
painless  or  refers  the  symptoms  to  the  renal  zone  below  the  ribs  near 
the  spine  behind  and  the  hypochondria  in  front  or  the  course  of  the 
ureters.  Objectively,  rectal  examination  in  cystitis  elicits  pain,  tender- 
ness and  sometimes  prostatic  engorgement,  but  in  renal  conditions 
negative  signs.     Abdominal  palpation  in  cystitis  reveals  a  tender 


CYSTITIS  173 

thickened  })la{l<ler  and  nothing  in  the  kichiey  and  ureteral  zones,  but 
in  kidney  lesions  the  })ladder  is  usually  negative  while  the  ureterorenal 
regions  show  pain,  tenderness  and  enlargement.  Cystoscopy  in  cystitis 
gives  typical  findings  with  clear  urine  from  each  kidney,  whereas  in 
renal  disease  one  or  })oth  ureteral  mouths  may  be  i)r(jfoundly  changed 
and  show  an  outflow  of  pus  or  bloody  urine  or  no  urine.  Catheteriza- 
tion of  the  ureters  will  further  distinguish  the  point  of  chief  involve- 
ment, and  the  dye  tests  will  show  the  comparative  function  between 
the  two  sizes.  In  the  laboratory  sedimentation  is  rapid  in  cystitis 
and  the  urine  usually  alkaline  and  less  commonly  acid,  but  the  pus  of 
kidney  lesions  is  more  frequent  in  acid  urine  of  recent  cases  and  less 
so  in  alkaline  urine,  except  in  old  cases.  Renal  pus,  moreover,  settles 
out  much  more  slowly  with  somewhat  less  distinction  as  to  layers. 
Albumin  is  marked  in  kidney  disease  but  slight  and  proportional  with 
the  amount  of  pus  in  inflammation  of  the  bladder.  The  microscope 
detects  only  bladder  epithelia*and  other  elements  in  cystitis  to  the 
exclusion  of  kidney  signs  but  the  reverse  when  the  latter  organs  are 
involved,  so  that  then  casts  and  all  forms  of  ureteral,  pelvic  and  tubal 
epithelia  are  abundant.  The  radiograph  will  sometimes  reveal  changes 
in  the  size,  form  and  contents  of  one  or  both  kidneys  especially  if 
injected  with  impervious  fluids  like  the  more  modern  silver  salts. 
Stones,  if  present  as  the  source  of  the  infection,  are  almost  always 
detected  by  the  procedure. 

Treatment  of  Gonococcal  Acute  and  Chronic  Urethrocystitis  and  Cystitis. 
—These  two  lesions  should  be  grouped  together  as  cognate  and  differing 
only  in  degree  and  duration  of  treatment  and  significance  makes  the 
urethrocystitis  relatively  rather  minor  until  it  merges  into  a  cystitis 
as  distinctly  major.  The  prophylaxis  heads  the  earliest  sign  of  invasion 
of  the  bladder  by  immediately  applying  the  subjoined  elements  of 
treatment  and  especially  by  rendering  the  urine  antiseptic  and  aseptic. 
Early  and  proper  attention  to  posterior  urethritis,  as  fully  described 
on  page  76,  is  also  preventive,  while  abortion  is  possible  by  lavage 
of  the  bladder  during  acute  retention  often  seen  in  severe  posterior 
urethral  lesions.  Any  invasion  of  the  bladder  during  infection  of  the 
urethra  must  be  followed  by  irrigation,  retention  of  mild  antiseptic 
fluid  and  retrojection  with  it  and  by  the  administration  of  suitable 
urinary  antiseptics. 

Brevity  requires  reference  to  Chapter  IX  on  General  Principles 
Treatment  for  description  of  management  on  page  483. 

Curative  Treatment. — Too  much  stress  cannot  be  laid  on  the  special 
features  of  each  case. 

The  physical  measm'es  are  comparatively  of  little  mfluence  until 
later,  especially  massage,  which  is  an  eliminant  in  the  toxic  cases. 
Cold  and  heat  locally  applied  with  the  ice-bag  or  poultice  represent 
hydrotherapy.  Rectal  irrigation  with  cold  or  hot  fluids  will  quiet  the 
irritation  and  tenesmus,  while  hot  sitting  baths  reduce  the  deep  pelvic 
congestion.  Hot  body  baths  and  Tiu-kish  baths  stimulate  perspiration 
and  elimination  to  great  advantage  in  severe  absorptive  cases. 


174     COMPLICAriOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

The  a])])licatioii  of  liijht  is,  as  noted  on  i)a,i:;o  ISS,  a  con\-onicMit  moans 
of  local  heat  to  the  ])erineal  and  supra])nl)ic  regions  in  lon<:;  and  fre- 
quent sittings  until  the  skin  is  very  red.  In  acute  cases  it  is  a  sedative 
and  deconc;estant  and  easy  for  the  patient  to  use  himself. 

The  electrotherajHnities  re(iuire  a  multii)le  ])late,  hifjh-speed  static 
eleetrieal  machine  deAelojiini:  u])  to  o  milliamperes  of  current  and  a 
7  inch  to  S  inch  .r-ray  tube  capable  of  backing  up  r)(),0()l)  volts.  The 
intensity  of  current  is  measured  at  from  2  to  5  milliamperes,  the  dis- 
tance from  the  ])art  is  10  inches  with  filtration  through  3  mm.  of 
aluminum  combined  with  either  4  thicknesses  of  chamois  or  one  thick- 
ness of  sole  leather.  The  duration  is  twenty  minutes  and  twice  a 
week  is  the  frequency.  The  action  is  inhibitory  on  the  organisms  and 
stimulant  of  resorption  of  the  exudate.  A  series  of  twenty  treatments 
should  be  given,  rej^eated  after  two  weeks,  and  in  th(>  interval  helio- 
therajiy  may  be  applied. 

The  medicinal  measures  in  all  known  means  by  systemic  adminis- 
tration are  employed  to  combat  absorption  and  toxemia,  to  render 
the  urine  antiseptic  against  extension  of  infection  to  the  kidneys  and 
to  stimulate  the  mucosa  to  improved  action  especially  during  the  declin- 
ing jxriods.  The  drugs  are  the  same  as  those  recommended  for  the 
medicinal  measiu'es  for  urethritis  on  page  67. 

The  serotherapy  is  not  encouraging,  but  is  more  s'o  in  subacute 
and  chronic  than  acute  lesions.  In  particular  the  negative  phase  must 
be  guarded  against  and  the  serum  is  preferred  for  passiAc  immunity 
and  the  bacterin,  either  autogenous  or  heterogeneous  or  mixed,  as  ^'an 
Cott's,  is  given  for  active  immunity.  No  such  remarkable  results  as 
in  diphtlieria  may  be  ex^Dected  but  many  cases  are  aided  by  properly 
graduated  and  increasing  doses,  as  mentioned  in  this  subject  in 
Chapter  IX  on  General  Principles  of  Treatment  on  page  513. 

All  local  administration  during  acute  symptoms  should  be  stopped 
and  only  in  the  subacute  declining  stages  may  vesical  irrigation  be 
begun — most  adA'isedly  with  the  soft  catheter-s\Tinge  method,  always 
after  the  patient  has  urinated  to  cleanse  the  lU'ctlu-a.  Lavage  is  made 
in  small  Cj[uantities,  from  30  to  100  c.c.  (1  to  3  ounces),  at  each  filling 
at  first,  heated  to  easy  tolerance  from  95°  to  110°  F.,  of  nonirritating 
chemical  character,  such  as  normal  salt  solution,  boric  acid  water  2 
to  4  per  cent.,  nitrate  of  silver  1  in  20,000,  potassium  permanganate 
1  in  20,000  to  10,000,  argyrol  3  to  10  per  cent,  and  similar  familiar 
solutions.  Washing  is  continued  with  the  solvents  of  pus,  such  as  the 
first  two  solutions,  until  the  return  fluid  is  clear,  showing  that  the 
muco.sa  is  freed  of  exudate  and  then  antiseptic  and  the  astringent 
solutions,  such  as  the  last  three  formulas,  are  used  and  commonly  a 
fourth  or  third  of  the  bladfler  capacity  is  left  in  for  more  prolonged 
action.  There  must  be  only  trivial  pain,  spasm,  tenesmus  or  other 
reaction  and  the  retained  fluid  when  e^"acuated  is  a  retrojection  for 
the  urethritis  and  therefore  has  (l()u])le  function.  The  frecpiency  of 
lavage  is  at  first  twice  a  day,  then  once  a  day  and  next  alternate  days 
and  finally  longer  inter^'als  determined  by  the  power  of  the  bla.dder  to 


CYSTITIS  175 

throw  off  accumulated  pus.  Instillation  of  the  flcep  urethra  and  (;ven 
the  neck  of  the  bladder  in  the  later  stages  of  cystitis  may  he  begun 
with  advantage  according  to  indications  and  results.  I'he  fluids  and 
strengths  duplicate  those  given  under  urethritis.  With  discrimination 
this  treatment  is  almost  abortive  of  urethrocystitis  in  the  earlier  jKjriofl. 
When  the  cystitis  is  far  declined  urethral  irrigations  by  the  surgeon 
and  hand  injections  by  the  patient  may  be  with  caution  instituted  to 
avoid  any  disturbance  or  relapse  of  the  cystitis.  Again  the  catheter- 
syringe  method  is  the  choice. 

The  surgical  treatment  is  nonoperative  and  operative.  The  non- 
operative  surgical  measures  apply  to  the  early  symptom  of  acute 
retention  by  catheterism  at  one  or  a  few  sittings  in  mild  attacks  or  by  a 
retention  catheter  in  severe  cases  to  avoid  frequent  incursion  of  the 
viscus,  combined  with  the  same  gentle  irrigation  just  described.  Instru- 
mentation is  very  late,  only  after  the  cystitis  is  almost  well,  and  the 
author's  sound  is  best  in  combining  gentle  dilatation  of  stricture  ante- 
cedent to  the  posterior  urethritis  and  its  complicating  cystitis  with 
lavage  of  the  bladder,  retention  of  medicated  fluid  and  retrojection 
of  the  same.  All  the  principles  are  the  same  as  those  given  for  urethral 
irrigation,  instrumentation,  and  dilatation  with  mechanical  methods 
on  page  365. 

The  operative  surgical  methods  are  reserved  for  failure  of  all  other 
means  and  the  terminal  stages.  Through  the  cystoscope  and  cysto- 
urethroscope,  as  defined  in  Chapters  XII  and  XIII  on  pages  653  and 
682,  applications  may  be  made  to  the  mucosa  of  sedatives,  stimulants, 
astringents  and  caustics  and  even  the  high-frequency  current  of  Oudin 
to  localized  patches  of  rebellious  inflammation  and  indolent  ulcers  always 
within  any  severe  reaction  or  relapse.  Ureteral  catheterism  will  deter- 
mine involvement  of  the  kidneys  and  should  be  carried  out  with  the 
technic  detailed  under  this  subject  on  page  821.  Careful  lavage  and 
reasonable  sterilization  of  the  bladder  are  essential  preliminaries.  The 
minor  operations  include  only  suprapubic  aspiration  in  cases  of  severe 
retention,  from  a  stricture  impassable  to  a  catheter.  Suprapubic  aspira- 
tion is  only  required  in  a  bladder  known  to  be  distended  well  above  the 
symphysis  pubis  by  inspection,  percussion  and  abdominal  and  rectal 
palpation.  Strict  asepsis  and  antisepsis  as  to  the  skin  of  patient  and 
surgeon  and  the  instruments  and  supplies  with  the  patient  supine. 
After  local  anesthesia  and  a  small  trocar  and  cannula  or  an  aspirating 
needle  with  sjTinge  is  entered  just  above  the  symphysis  and  pointed 
10°  to  15°  downward  and  backward  and  carried  into  the  cavity  of  the 
bladder  practically  at  the  upper  border  of  the  bones.  The  trochar  is 
Ihen  removed  for  free  outlet  of  the  urine  under  pressm-e  of  the  disten- 
tion or  if  it  does  not  flow  through  the  aspirating  needle  suction  with  the 
syringe  will  start  it.  If  distention  has  been  extreme  only  about  half 
should  be  withdrawn,  otherwise  hemorrhage  into  the  bladder  may 
result  from  undue  removal  of  pressure  from  the  capillaries.  After 
withdrawal  of  the  instrument  there  is  usually  no  leakage  or  infection 
of  the  cellular  planes,  especially  if  the  needle  is  chosen.  A  small  dressing 


176     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

with  collodion  is  sufficient.  This  relief  of  the  bladder  combined  with 
other  measures  will  often  make  an  impassable  stricture  ])assable  or 
remove  other  cause  of  the  retention  and  ])ermit  other  forms  of  treat- 
ment. Major  operations  are  perineal  drainage  through  a  combined 
internal  and  external  urethrotomy  or  through  the  "button-hole" 
operation  or  a  su]n-apubic  cystotomy. 

Urctltr()fo))iy  is  described  under  the  Treatment  of  Stricture  on  page 
390  and  need  not  be  repeated  here. 

Suj)ra}>ubic  cysfof(»in/  contains  the  following  details:  It  is  less  fre- 
quently done  than  perineal  drainage  and  in  selection  of  case  respects 
those  benefited  by  topical  ajiplications  as  ])art  of  the  procedure.  As  in 
any  laparotomy  the  instruments  and  supplies  are  scalpels  with  short 
and  long  blades,  scissors,  hemostats  and  ligatures,  forceps  and  retractors 
both  sharp  and  blunt,  long  and  short  blade,  illumination  for  the  cavity 
of  the  bladder,  needle-holder,  needles  and  sutm-es,  drains  and  dressings. 
The  ])re])aration  of  patient  and  field  is  standard  for  any  major  opera- 
tion antl  the  anesthesia  may  be  local  with  careful  infiltration  of  the 
nerves  of  the  skin  and  muscle  planes  and  the  posture  is  supine,  giving 
the  landmarks  of  the  symphysis  pubis  below  and  the  umbilicus  above 
for  the  incision,  which  passes  above  the  former  for  about  three  inches 
in  the  middle  line  through  the  superficial  field  between  the  rectus 
muscles  down  to  the  extraperitoneal  fat.  Ilemostasis  and  retraction 
follow  and  then  the  fingers  in  the  deep  field  are  passed  laterally  to 
reach  the  fold  of  peritoneum  as  it  turns  forward  and  inward  over  the 
viscus  and  makes  an  interval  easy  of  detection  and  separation  from  the 
bladder  so  that  freedom  of  its  transverse  border  is  immediate.  A  needle 
with  stout  silk  suture  is  now  passed  into  the  bladder  high  up  on  each 
side  as  elevators  and  retractors  between  which  a  stab  of  the  bladder  is 
made  and  the  outflow  caught  on  gauze.  Carefid  diagnosis  and  treat- 
ment of  the  m-ethral  condition  must  be  made  from  within  the  bladder 
forward  as  part  of  this  operation,  as  discussed*  under  Treatment  of 
Stricture  by  the  Retrograde  Operation  after  Cystotomy  on  page  402. 
As  little  separation  as  possible  of  the  bladder  from  the  s^Tiiphysis  is 
made  so  that  the  deep  field  is  above  and  not  behind  this  joint  and 
pocketing  of  drainage  is  avoided.  After  suitable  enlargement  of  the 
wound  in  the  bladder  and  inspection  and  suitable  applications  or  other 
required  treatment  to  its  cleansed  cavity  are  made,  the  drainage  tube 
is  inserted  and  the  wall  stitched  with  two  or  more  layers  of  Lembert 
mattress  sutm-es  down  to  it.  The  tube  is  stitched  to  aponeurosis, 
fascia  or  skin  with  light  catgut  and  the  abdominal  wound  is  reason- 
ably closed  with  layer  sutures  of  catgut  and  silkworm  gut  for  the  skin. 
A  large  standard  dressing  receives  the  drainage  or  one  of  the  various 
suction  devices  may  be  attached  to  the  tube  to  keep  the  bladder  free 
of  accumulation. 

Aftertreatmeni.  —  Immediate  steps  secure  regular  drainage  of  the 
bladder  associated  with  irrigation  as  already  described  and  with 
urethral  treatment  as  required,  and  dressings  changed  every  two  to 
four  hours  for  absolute  freedom  from  decomposing  urine.    The  drain  is 


URETERITIS,  PYELITIS  AND  PYELONEPHRITIS  177 

removed  on  the  third  to  the  seventh  day  and  the  skin  stitches  on  the 
seventh  to  tenth  day  if  possible.  Nursing,  diet  and  medication  are 
according  to  indications.  Remote  aftercare  prevents  relapse  of  urethral 
conditions  from  which  the  cystitis  arose  and  any  cause  tending  to 
reproduce  the  cystitis.  After  secondary  intention  has  healed  the  wound, 
therefore,  all  the  aftertreatment  of  stricture  and  posterior  urethritis, 
given  on  page  399,  and  that  for  cystitis,  stated  on  page  329,  must  be 
in  evidence  as  prophylaxis  of  persistence  or  relapse.  The  comments 
acknowledge  that  this  operation  is  without  much  danger,  but  must 
have  the  caution  of  not  wounding  the  peritoneum.  Shock  is  minimal, 
benefit  great  and  end  results  of  great  value,  often  preventing  a  pan- 
cystitis  with  contracture. 

Constitutional  aftertreatment  of  cystitis  is  sufficiently  indicated  in 
each  of  the  foregoing  measures  and  includes  fit  attention  to  systemic 
causes  and  to  local  causes.  These  are  enumerated  in  the  clinical 
section  but  of  special  importance  are  restoration  of  the  bladder  and 
urethral  mucosa  to  as  near  their  normal  condition  as  possible  and  the 
relief  of  pus  foci  in  the  prostate,  seminal  vesicles,  posterior  urethra  and 
finally  in  stricture  formations.  Any  such  lesions  persisting  largely 
defeat  the  result  because  they  invite  active  relapse  within  themselves 
and  within  the  bladder. 

Cure. — Cure  pathologically  can  occur  only  in  the  mildest  cases.  The 
process  may  be  checked  so  that  normal  physiology  results  and  only 
scattered  sequels  such  as  infiltrations  remain.  Symptomatically  in 
general  a  weakened  bladder  results  so  that  any  exciting  cause,  such  as 
diet,  drink  and  exposure  to  cold,  may  be  followed  by  a  relapse  particu- 
larly if  the  patient  has  a  catarrhal  or  other  tendency.  In  the  severe 
cases  mild  relapses  are  very  frequent  and  a  few  patients  have  a  sub- 
cystitis  more  or  less  constantly  without  other  disadvantage.  In  other 
words,  like  every  other  mucosa  that  of  the  bladder  may  never  really 
recover  if  deeply  damaged.  Bacteriologically  disappearance  of  the 
gonococci  is  most  important  together  with  its  pyogenic  allies. 


URETERITIS,  PYELITIS  AND  PYELONEPHRITIS. 

Occurrence. — ^As  complications  of  posterior  gonococcal  acute  ure- 
thritis these  three  conditions  are  rare  and  regularly  caused  by  invasion 
of  kidney,  pelvis  and  ureter  on  one  or  both  sides  by  the  gonococcus,  in 
pure  culture  least  commonly,  but  in  mixed  culture  most  commonly. 
As  in  so  many  other  urogenital  infections  the  staphylococcus,  strepto- 
coccus and  Bacillus  coli  communis  of  the  pyogenic  group  are  the  usual 
associates. 

Definition. — Strictly  infection  of  the  ureter  alone  is  ureteritis,  which 
rarely  occurs  excepting  with  the  pelvis,  constituting  pyelitis.  Almost 
invariably  the  latter  term  carries  with  it  involvement  of  the  ureter. 
In  ureteropyelitis,  therefore,  the  kidney  substance  itself  escapes  more 
or  less  fully.  Pyelonephritis  means  involvement  of  the  parenchyma 
12 


17S     COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

of  the  kidney  in  the  infection,  so  that  signs  of  inflammation  of  the 
kichiey  are  regularly  present. 

Varieties. — ^'aricties  arc  considered  as  primary  and  secondary  as  to 
origin;  acute,  subacute,  chronic  and  relapsing,  compHcated  and  uncom- 
plicated as  to  course;  mild,  severe  and  intense  as  to  degree;  nongono- 
coccal and  gonococcal  as  to  cause;  unilateral  and  bilateral  as  to  loca- 
tion. Of  these  the  primary  cases  do  not  concern  this  work  as  it  deals 
only  A\-ith  their  relation  to  antecedent  gonococcal  infection,  thus 
bringing  all  cases  under  the  secondary  class.  For  the  same  reason  the 
nongonococcal  grouj)  may  be  merged  into  the  gonococcal,  remembering 
that  catarrhal  pyelitis  and  supI)urati^■e  pyelitis  have  the  same  but  less 
marked  clinical  pictures.  As  to  mode  of  infection  ascending  cases  and 
descending  cases  are  distinguished.  In  the  former  the  ureter  becomes 
dilated  and  the  organisms  travel  upward  from  the  bladder  or  pass 
along  the  lymphatics  to  the  kidney  but  in  the  latter  the  kidney  is 
invaded  by  bacteria  through  the  bloodstream  or  the  lymphstream 
and  after  free  production  of  pus  in  the  urine  the  process  descends 
along  the  ureter. 

Etiology. — As  in  all  infections  there  are  predisposing  and  exciting, 
local  and  systemic  elements.  The  predisposing  systemic  causes  are 
those  diatheses  which  incline  through  low  resistance  to  infection  and 
catarrhal  conditions.  Occasionally  these  become  exciting  systemic 
factors.  The  predisposing  local  elements  are  congestion  and  irritation 
of  the  kidney,  pelvis  and  ureter  by  food,  drink,  drugs,  exposure,  exertion 
and  traumatism.  Injudicious  use  of  the  balsams  is  not  an  infrequent 
distm-bance  of  the  kidney.  Kidneys  depreciated  by  antecedent  medical 
nephritis  or  tramnatism  are  much  more  vulnerable  to  invasion  by  the 
gonococcus  and  other  organisms  than  are  sound  kidneys,  hence  the 
scarlatinal  nephritis  of  childhood  is  often  a  precursor  of  these  compli- 
cations. 

The  exciting  local  factor  is  regularly  the  gonococcus,  with  or  without 
the  pyogenic  group.  The  avenues  of  invasion  are  the  ureter,  the  blood- 
stream and  the  lymj^hatic  channels.  (1)  Through  the  ureter  the  gono- 
coccus ascends  from  the  bladder  in  continuity  of  their  mucostc,  induced 
by  back  pressure  of  obstruction  chiefly  through  stricture,  prostatic 
abscess  and  hypertrophy.  The  mouths  of  the  lu-eters  are  commonly 
gaping,  their  sjihincters  relaxed  and  inactive  so  that  an  open  channel 
exists  from  the  bladder  to  the  pelvis  and  the  kidney.  (2)  Through 
the  blood  current  the  gonococcus  reaches  the  kidney  as  infarcts 
originating  in  severe  lesions  of  posterior  urethritis  and  prostatitis.  In 
these  cases  the  pathogenesis  is  the  same  as  in  gonococcal  infection  of 
joints,  tendon  sheaths  and  endocardium.  The  absence  of  cystitis  is 
essential  as  in  this  form  the  nephritis  precedes  and  the  ureteropyelitis 
follows.  (3)  Through  the  l^inphatic  channels  the  gonococci  reach  the 
perirenal  substance  along  the  lymphatics  which  follow  the  course  of 
the  ureter.  From  foci  so  established  the  pus  invades  the  kidney  sub- 
stance so  that  the  nephritis  is  again  the  first  element  and  the  pyelitis 
and  ureteritis  second. 


URETERITIS,  PYELITIS  AMI)  PYELONEI'IIRITIH  179 

Cases  in  literature  are  very  fr(;(nu!rit  and  tli(;ir  nunii)er  iniglit  he 
indefinitely  quoted.  The  following  few,  however,  are  proof  of  the  oeeur- 
rence  of  this  complication  either  through  the  gonococcus  in  pure  culture 
or  through  its  association  with  other  pyogenic  organisms.  Ilagner^ 
has  recorded  27  cases  of  his  own,  9  with  pure  and  IG  with  mixed  gono- 
coccal invasion.  Sellei  and  Unterberg^  report  5  cases  of  infection  of 
the  kidney  with  the  Bacillus  coli  communis  and  gonococcus  together. 
Bransford  Lewis^  discusses  the  general  pathology  and  subject. 

Pathology. — The  lesions  are  unilateral  or  bilateral.  Primary  cases 
without  known  precursor  of  acute  or  chronic  infective  focus  are  rare 
and  do  not  concern  this  work.  Secondary  cases  are  the  rule,  especially 
after  gonococcal  cystitis,  acute  and  chronic  posterior  urethritis,  pros- 
tatitis and  seminal  vesiculitis  with  or  without  abscess.  The  exciting 
organism  is  the  gonococcus  more  frequently  with  the  pyogenic  group 
than  without  them.  The  essence  of  the  process  in  ureteritis  and  pye- 
litis is  gonococcal  infection  of  the  mucosa  and  submucosa,  characterized 
by  congestion,  desquamation,  infiltration,  thickening,  mucus-  and  pus- 
formation,  bleeding  and  ulceration,  all  in  severity  proportional  with 
the  activity  of  the  organisms.  The  renal  substance  is  hyperemic  in 
sympathy  only  and  does  not  share  directly  in  the  infection.  The  tissues 
involved  are,  therefore,  the  lining  of  the  ureter,  the  pelvis  of  the  kidney 
and  its  calyces,  in  the  mucosa  alone  in  mild  cases  or  the  submucosa 
and  stroma  of  the  canal  in  severe  cases.  The  temporary  lesions  are 
seen  only  in  mild  degrees  which  hardly  pass  beyond  the  catarrhal 
stage,  but  the  permanent  results  appear  after  severe  or  repeated  attacks 
and  are  characterized  chiefly  by  thickenings,  fibrosis,  stricture  and 
kinking  of  the  ureter  and  thickening  deformity  and  sacculation  of  the 
pelvis.  The  associated  lesions  are  practically  always  the  antecedent 
infections  in  the  distal  urinary  tract  in  ascending  forms  or  in  the 
proximal  urinary  tract,  namely,  in  the  kidney  in  descending  types  of 
hematogenous  or  lymphogenous  origin. 

The  essence  of  the  process  in  pyelonephritis  is  a  gonococcal  attack 
upon  the  parenchyma  of  the  kidney,  so  that  the  element  of  infection  of 
the  kidney  is  preeminent.  The  tissues  attacked  are  the  stroma,  glo- 
meruli, proximal  tubules  and  distal  tubules  in  a  generalized  or  focalized 
infection.  The  abscesses  are  of  microscopic  or  macroscopic  size,  in 
multiple  spots  and  streaks.  General  nephritis  of  variable  degree  may 
occur  in  which  the  epithelium  is  degenerated,  the  glomeruli  congested, 
infiltrated  with  small  round  cells,  hypertrophied  or  atrophied,  the 
tubules  hypertrophied  and  dilated  or  atrophied  and  obliterated  and 
filled  with  blood,  pus  and  casts.  Temporary  lesions  hardly  ever  occur 
as  the  kidneys  are  invariably  damaged,  but  the  degree  may  be  so 
slight  as  to  leave  physiologically  serviceable  organs,  in  that  sound  por- 
tions compensate  for  lost  or  damaged  areas.  The  permanent  lesions 
are  the  scars  of  the  abscesses  and  the  sequels  in  the  secretory  portion 
of  the  organ  just  described.    The  associated  lesions  are  the  precursors 

1  Med.  Rec,  1910,  p.  568.  =  ggrl.  klin.  Wchnschr.,  1907,  sliv,  p.  1113. 

5  Jotir.  Cut.  and  Gen.-Urin.  Dis.,  1900,  x-^dii,  395. 


ISO     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

of  the  infection  in  the  distal  urogenital  tract  and  in  the  pelvis  and 
mvter  in  the  descending  form  with  the  kidney  first  involved. 

Symptoms.  -There  are  ini])ortant  ditterences  between  the  ascending 
anil  descending  types  of  the  disease. 

A.  The  following  conditions  are  intrinsic  chieHy  for  (t.srcndliig  infec- 
tion of  the  ureter,  y^r/r/.v  and  hidnei/  which  connnonly  proceeds  in  the 
order  of  parts  named  although  the  i)rocess  may  he  so  severe  as  to 
constitute  one  entity.  Careful  description  respects  subjective  and 
objectiA'e,  systemic  and  focal  symptoms  during  invasion,  establish- 
ment and  termination.  All  vary  with  the  acuteness  and  severity  of 
the  attack  and  all  are  fewest  in  the  mild  lesions. 

The  mild  symptoms  belong  necessarily  to  the  less  extensive  as  well 
as  the  less  severe  lesions  and  are  consequently  seen  in  ureteritis  and 
pyelitis  without  involvement  of  the  kidney  in  any  process  more  than 
congestion.  On  the  other  hand,  the  severe  symptoms  obviously  are 
inherent  in  the  more  profound  and  intense  lesions  in  which  the  kidney 
is  greatly  compromised,  so  that  these  patients,  therefore,  have  all  the 
sxTnptoms  of  profound  nephritis. 

1.  The  period  of  invasion  of  pyelitis  is  not  well  marked,  being  as  a 
rule  merged  with  the  antecedent  source  of  the  gonococci.  The  systemic 
subjective  symptoms  are  either  practically  absent  in  mild  cases  or  in 
severe  forms  follow  the  rule  in  most  infections  with  sudden  onset  of 
anorexia,  nausea,  vomiting  and  constipation,  chill  or  chilliness,  fever, 
perspiration  and  prostration.  The  patient  gladly  takes  to  bed  and 
ai)pears  sick.  The  local  subjective  symptoms  are  discomfort,  dragging, 
positive  pain,  pollakiiu'ia,  dysuria,  anuria  and  referred  pain. 

In  mild  cases  discomfort  and  dragging  and  in  the  severe  cases  posi- 
tive pain  are  present.  Pain  in  the  kidney  region  on  deep  inspiration, 
coughing  or  other  motion  is  also  often  complained  of.  The  pain  is  due 
to  the  congestion,  the  irritation  of  the  urine  upon  the  diseased  mucosa 
and  the  passage  of  pus  and  mucus  down  the  ureter  acting  much  as 
gravel  and  calculi  do.  Pollakiuria  is  often  marked  and  adds  to  that 
already  existent  from  vesicle  and  urethral  conditions.  Dysuria  is 
usually  of  reflex  origin  and  likewise  temporary  anuria.  Pain  may  be 
referred  to  the  normal  side  in  unilateral  cases  and  is  then  due  to  con- 
gestion of  the  healthy  kidney  during  its  compensatory  effort.  Referred 
pain  may  also  be  sympathetically  in  the  testicle  and  cord  of  the  same 
sifle,  and  is  due  to  the  descent  of  slugs  of  pus  and  mucus,  exactly  as  in 
migrating  ureteral  calculi. 

The  systemic  and  local  objective  symptoms  of  the  invasion  are  very 
difficult  to  distinguish  from  the  antecedent  condition  in  the  m-ethra, 
prostate,  seminal  vesicles  or  bladder  in  either  the  ascending  or  descend- 
ing cases,  unless  it  be  perhaps,  the  conditions  within  the  urine  which 
on  analysis  reveals  the  advent  of  pelvic  and  at  tunes  renal  elements 
previously  known  to  be  absent  in  well-followed  cases. 

The  systemic  and  local  subjective  and  objective  symptoms  of  the 
stage  of  establishment  are  the  same  as  those  just  described  with  the 
degree  much  more  marked.     In  fact,  it  is  dm'ing  the  establislmient 


URETERITIS,  PYELITIS  AND  PYELONEPHRITIS  181 

that  the  symptoms  are  usually  complained  of  enough  to  render  the 
diagnosis  positive.  The  insidious  onset  and  invasion  more  or  less 
masked  by  the  preceding  com])lifated  urethritis  render  very  early 
recognition  most  difficult. 

2.  The  inmsion  of  jjyelonejihritis  is  a  much  more  severe  and  i>ros- 
trating  condition  with  all  the  foregoing  symptoms  present,  including 
scanty  urine,  loaded  with  pus,  blood,  casts,  bacteria,  detritus,  albmnh), 
and  high  specific  gravity.  As  a  rule  it  is  acid  at  first,  then  alkaline 
as  the  age  of  the  disease  advances.  The  establishment  in  subjective 
symptoms  is  marked  by  continuation  of  the  chills  or  chilliness,  fever, 
debility,  pain,  oliguria  and  at  times  crises  of  anuria.  The  picture  is 
one  of  multiple  pus  foci  in  the  kidney  or  of  general  suppuration  of  the 
parenchyma  which  involves  a  severe  infectious  condition  with  rapid 
pulse,  fever  and  extreme  weakness.  If  the  ureter  is  draining  well  and 
if  the  pus  is  evacuated  into  the  pelvis  rather  freely  instead  of  being 
retained  in  abscesses,  the  symptoms  are  apt  to  be  less,  but  if  retention 
is  present  either  through  occlusion  of  the  ureter  or  through  phlegmon- 
ous nephritis,  then  the  s;vTiiptoms  are  all  augmented.  The  pain  may 
be  unilateral  or  bilateral  and  is  greatest  when  the  ureter  is  blocked 
and  the  first  steps  of  pyonephrosis  present.  Even  if  one  kidney  is 
involved,  the  congestion  of  the  normal  kidney  through  double  duty 
may  lead  to  pain  in  it  for  a  time.  The  pain  is  referred  as  in  calculi 
to  the  loins,  down  the  ureter,  to  the  bladder,  testis,  penis  and  even  the 
thigh.  The  condition  of  the  ureter  and  passage  along  it  of  masses  of 
pus  and  detritus  are  probably  the  origins  of  these  referred  pains. 
Oliguria  is  seen  during  the  invasion  as  long  as  the  congestion  of  the 
normal  kidney  in  unilateral  cases  lasts  and  in  bilateral  cases  until  the 
kidneys  may  begin  to  improve.  Anm-ia  which  may  be  temporary  and 
then  augment  all  the  other  symptoms  or '  persistent  and  then  end 
fatally  is  not  uncommon  in  extreme  cases.  Profuse  perspiration  of 
the  skin  always  accompanies  either  of  these  symptoms.  The  systemic 
local  objective  symptoms  of  the  establishment  verify  the  foregoing  con- 
ditions as  of  renal  origin.  The  strength  of  the  patient  is  on  inspection 
obviously  attacked  so  that  he  looks  feverish,  infected,  sick  and  pros- 
trated. Palpation  of  the  kidney  zones  is  not  absolutely  diagnostic 
unless  the  patient  is  able  to  relax  his  abdomen  and  the  kidney  is 
enlarged.  Occasionally  one  of  both  organs  are  found  enlarged,  tense 
and  sensitive  with  tenderness  along  the  ureter.  In  unilateral  cases 
the  afflicted  kidney  shows  these  signs  while  the  normal  one  may  be 
only  tender,  and,  of  course,  in  bilateral  cases  these  data  may  be  elicited 
on  both  sides  equally  or  on  one  side  considerably  more  than  on  the 
other  side. 

1.  Laboratory  findings,  if  the  ureter  is  draining,  are  a  scanty  urine 
of  high  specific  gravity,  acid  in  recent,  alkaline  in  older  cases,  especially 
those  with  retention  and  decomposition  of  the  urine  in  the  pelvis  of 
the  kidney,  serumalbumin  from  the  blood  and  nucleoalbumin  from 
the  pus,  multiple  casts,  including  epithelial,  blood  and  pus  casts,  pus 
cells  in  various  stages  of  degeneration,  red  blood  cells  in  moderate 


1S2     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

or  marked  amount,  mucus  and  other  detritus.  The  iionococcus  in 
pure  or  associated  culture  with  many  other  organisms  is  present. 
2.  If  the  ureter  is  not  draining,  then  the  urine  may  show  only  the  con- 
ditions of  the  antecedent  cystitis  in  ascending  cases  or  of  the  previous 
com])licatcd  urethritis  in  descending  cases.  With  one  kidney  involved 
and  its  ureter  blocked,  the  congested  normal  kidney  maA-  show  the 
characteristic  elements  of  its  disturbance. 

Sedimentation  of  the  m-ine  shows  the  usual  layers  of  dense  pus  and 
detritus  at  the  bottom  followed  from  below  upward  by  a  layer  of  less 
specific  graAity  containing  the  blood,  then  one  with  mucopus  and  less 
blood,  and  finally  one  of  mucus  and  urine  itself. 

Cystoscopy  may  be  advisedly  done,  if  the  declining  stage  of  the 
urethritis  and  cystitis  is  present.  This  procedure  will  settle  the  diag- 
nosis, especially  when  combined  with  ureteral  catheterization.  The 
latter  step  will  recognize  not  only  the  side  affected  in  unilateral  cases 
but  the  more  involved  kidney  in  bilateral  cases,  particularly  if  reten- 
tion and  decomposition  are  present  on  one  side  and  not  on  the 
other,  which  would  sometimes  giAC  respectively  alkaline  and  acid 
lu'ine. 

B.  Desceiidiiig  pyelonephritis,  pyelitis  and  ureteritis  re\'erse  the  order 
of  infection  of  parts  and  change  the  clinical  picture  in  the  following 
intrinsic  terms.  As  previously  stated,  the  som-ce  of  the  infection  is  the 
blood  current  or  the  lymphstream  from  some  active  gonococcal  focus 
in  the  genital  system  without  compromise  of  the  bladder.  The  renal 
lesions,  tlierefore,  come  first,  either  in  the  kidney  substance  itself, 
or  in  the  perirenal  tissues,  respectively  as  multiple  or  solitary  abscess 
or  general  suppuration  in  the  kidney  or  its  annexa.  From  this  condi- 
tion the  pus  passes  sooner  or  later  through  the  kidney  substance  into 
the  peh'is,  down  the  ureter  and  into  the  bladder,  setting  up  suppm-ation 
wherever  it  reaches.  The  systemic  and  local  subjective  and  objecti\e 
symptoms  are  the  same  as  those  described  for  the  ascending  type, 
except  that  at  the  outset  there  is  greater  intensity  of  the  renal  factor, 
essential  to  purulent  nephritis.  Daily  urinalysis  will  show  a  i)rofoand 
nephritis  even  before  macroscopic  pus  appears.  After  this,  urinalysis 
reveals  all  the  physical,  chemical,  microscopical  and  bacteriological 
features  w^hich  accompany  free  pus  in  the  urine.  This  brings  out  the 
practical  fact  that  e\-ery  case  of  severe  gonococcal  infection  with 
confinement  to  bed  requires  examination  of  the  urine  daily  or  every 
other  day  for  the  earliest  possible  discovery  of  such  extensions  and 
involvements  of  the  kidney. 

Termination  of  Ureteritis,  Pyelitis  and  Pyelonephritis.- — The  outlook 
of  complications  of  gonococcal  acute  m-ethritis  which  involve  such 
organs  as  the  kidneys  is  essentially  grave  in  virtue  of  the  permanence 
of  damage  inherent  in  the  action  of  the  gonococcus. 

1.  Pyelitis  and  ureteritis  in  mild  forms  are  followed  by  complete 
recovery  with  no  sequels,  but  such  are  relati^'ely  rare.  In  the  more 
severe  forms  a  damaged  and  w^eakened  mucosa  remains  behind  with 
thickenings  and  indurations  in  the  ureter  or  a  tendency  toward  relapses 


URETERITIS,  PYELITIS  AND  PYELONEPIl lUTIS  183 

or  frequent  attacks  of  catarrhal  inflammation.  Fiotii  1liis  l)iisis  the 
kidney  may  be  later  on  involved  as  a  remote  sequel. 

2.  Pyelonephritis  has  a  grave  outlook  for  the  kidney  itself  and  for 
life  in  some  cases.  Mild  involvement  of  the  kidnc^y  may  be  followed 
by  damage  so  slight  as  to  permit  full  function  of  the  sound  portioji  of 
the  organ,  but  severe  attacks  usually  mean  loss  of  one  kidney  function 
more  or  less  fully  in  the  form  of  chronic  pyelitis,  chronic;  pyelonephritis, 
pyonephrosis  or  abscess  and  perinephritic  abscess  combined  with  the 
former  conditions  and,  of  com-se,  with  profound  changes  in  the  ureter, 
as  stricture,  kinks  and  infiltrations.  When  both  kidneys  are  involved 
the  outlook  for  life  is  dismal.  The  patients  die  by  septic  absorption, 
uremia,  failure  of  the  opposite  kidney  to  compensate  during  the  acute 
onset  or  by  secondary  infection  sometimes  after  the  first  kidney  has 
become  destroyed  or  by  the  initial  intense  infection. 

Diagnosis  of  Ureteritis,  Pyelitis  and  Pyelonephritis. — Diathesis,  low 
resistance  and  previous  attacks  of  nephritis  are  usual  in  the  history, 
often  combined  with  acknowledged  habitual  or  incidental  errors  in 
diet,  drink,  drugs,  exposure  and  traumatism.  In  true  gonococcal 
cases  of  ascending  type  facts  are  elicited  concerning  severe  anterior 
urethritis  rapidly  invading  the  posterior  urethra  and  bladder  and  then 
reaching  the  kidney  either  by  direct  ascent  of  the  ureter  or  by  indirect 
attack  through  the  bloodstream  or  lymphstream.  Complicated  gono- 
coccal urethritis  especially  of  the  abscess  type  in  the  prostate  and 
seminal  vesicles  is  more  apt  to  present  the  infarct  variety  of  renal 
involvement.  Symptoms  subjectively  are  the  onset  of  profound 
infection  with  digestive  disturbance,  fever,  perspiration,  prostration 
and  the  feeling  of  being  deeply  sick.  Discomfort  increasing  to  varieties 
and  degrees  of  pain  in  the  renal  zone,  pollakiuria,  dysuria,  referred 
pains  and  the  usual  colic,  temporary  anuria  and  the  like  mark  the  local 
signs.  Objectively,  the  patient  is  really  sick  with  high  fever  and 
changed  pulse.  Palpation  usually  demonstrates  one  or  both  kidneys 
changed  in  one  or  more  particulars  as  to  size,  tenderness  and  consis- 
tency. If  the  ureter  is  draining  these  signs  are  less  than  when  it  is 
occluded.  Tenderness  and  bogginess  along  the  affected  ureter  are  not 
uncommon.  Cystoscopy  offers  recognition  of  an  absolutely  or  rela- 
tively normal  bladder,  recipient  of  pyuria  from  one  or  both  ureters 
showing,  as  a  rule,  profoundly  altered  mouths.  Catheterization  of  the 
two  ureters  establishes  their  permeability  and  the  degree  of  disease 
in  one  or  both  kidneys.  Functional  tests  complete  the  picture  and 
doubt  as  to  .r-ray  findings  is  removed  by  the  shadow  catheters  and 
silver  salt  solutions.  Laboratory  details  cover  the  bacteriology  of  the 
pus  recovered  and  the  elements  of  destruction  of  the  affected  kidney, 
while  treatment  directed  to  the  source  of  the  infection  indirectly  aid 
in  its  control.  Exact  anatomic  diagnosis  is  often  not  reached  until 
the  kidney  ite  under  operation  by  nephrotomy  or  nephrectomy. 

Chronic  ureteritis,  yyelitis  and  pyelonephritis  are  manifested  with  a 
history  of  acute  urethritis  followed  by  cystitis  and  ascendmg  infection 
or  of  metastatic  hematogenous  invasion  during  se^'ere  complications 


1S4     COMPLICATIOXS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

of  the  disease.  Subjectively  one  notes  low-grade  iullanimation  with 
definite  absorption  if  the  ureter  is  not  occluded  so  that  drainage  into 
the  bladder  is  constant;  but  if  it  is  occluded  tlisconifort,  pain,  oliguria 
and  anuria  are  not  unconunon,  whereas  objecti\'ely  fever  and  fe\erish- 
ness,  obvious  infection,  sickness,  prostration,  the  i)resence  of  a  tender 
mass  over  tlie  kidney  zone  increased  by  accumulation  of  pus  decreased 
by  its  evacuation  may  be  present.  Cystoscopy  and  ureteral  cathe- 
terization with  separated  urines  are  absolutely  essential  while  the 
laboratory  determines  the  kidney  efficiency  and  the  constituents  of 
the  specimens — physical,  chemical,  microscopic  and  bacteriological. 
During  occlusion  the  unatl'ected  side  shows  relatively  normal  urine. 
Treatment  aids  in  the  diagnosis  through  the  fact  that  antiseptics  and 
mild  measures  relicNe  less  active  cases  while  exposure  of  the  kidney 
followed  by  drainage  or  removal  supplies  the  anatomical  diag- 
nosis. 

Diiferential  Diagnosis. — Distinction  is  often  required  between  other 
conditions  causing  enlargement  of  or  pus  accumulations  hi  other 
abdominal  organs  and  ureteritis,  pyelitis  and  pyelonephritis.  The 
latter  tenn  embraces  more  or  less  fully  the  older  term  pyonephrosis. 
Such  conditions  are  on  the  left  side,  enlarged  spleen  and  neoplasm  of 
the  stomach;  on  the  right  side,  enlargement  of  the  liver,  inflammatory 
and  calcareous  distention  and  neoplasm  of  the  gall-bladder;  and  on 
both  sides,  subphrenic  and  perinephritic  abscess  among  infections  and 
among  neoplasms  benign  and  malignant  degenerations  of  the  kidne\', 
new  growth  of  the  colon  or  of  the  retroperitoneal  tissue.  Of  this  partial 
list  all  have  no  urinars'  signs  discoverable  by  cystoscopy,  ureteral 
catheterization  and  functional  test  except  perinephritic  abscess  in  some 
cases  by  outward  extension  from  a  localized  infection  of  the  kidney 
and  except  neoplasms  of  the  kidney  which  often  give  pus  and  blood  in 
the  urme  and  changed  function  of  the  organ.  In  general,  these  three 
means  of  in^'estigation  with  .r-ray  added  are  the  chief  means  of  differen- 
tiation. 

Enlarged  spleen  is  suggested  by  the  histor}'  of  leukemic  tendency, 
malarial  infection,  or  hepatic  enlargement  from  any  cause.  The 
s\Tnptoms  are  usually  slight  when  referred  to  the  spleen  itself  but 
comprise  weight,  draggmg  and  pain.  The  changes  in  the  organ  are 
recognized  by  its  position,  relation  to  the  ribs,  mobility,  consistency 
and  shape.  Enlargement  of  the  other  lymph  glands  will  further  prove 
the  diagnosis  of  leukemia.  Palpation  and  percussion  of  the  liver  will 
discover  any  hypertrophy  which  is  the  basis  of  the  splenic  enlargement. 
Radiography  is  of  great  ad\antage  in  rulmg  out  the  kidney  as  the  organ 
affected  and  finally,  cystoscopy,  separation  of  the  urines  and  functional 
tests  prove  that  the  urinary  system  is  not  at  all  compromised.  In 
the  laboratory  investigation  of  the  blood  shows  that  the  process  is  not 
purulent  and  that  malaria  or  leukemia  may  be  present.  The  urine  as 
obtained  from  the  bladder  and  by  ureteral  catheterization  is  normal. 
Treatment,  usually  medicinal,  directed  to  the  leukemia  or  malaria 
or  the  enlargement  of  the  liver  is  the  last  detail  of  diagnosis. 


URETERITIS,  PYELITIS  AND  PYELONEPHRITIS  185 

Neoplasm  of  the  stomach  offers  gastric  indigestion  as  the  chief  general 
picture  of  the  history.  (Ihronic  gastritis,  hernaterncsis,  acute  recurrent 
attacks  of  indigestion  and  inanition  are  cliief  aniojig  the  subjective 
symptoms.  The  tiunor,  if  pal]>af)le,  is  objectively  relatively  mobile 
and  in  cases  of  profound  involvement  cachexia  is  the  rule.  The  mass 
may  be  moved  directly  from  the  kidney  area.  Full  urological  investi- 
gation with  the  cystoscope,  ureteral  catheters,  functional  tests  and 
laboratory  analyses  rule  out  the  kidneys  and  ureters  from  considera- 
tion. Radiography  is  of  great  service  with  or  without  the  ingestion 
of  bismuth.  In  the  laboratory  test-meal  observations  must  not  be 
omitted  and  often  present  changes  in  the  chemistry  and  digestive 
power  of  the  gastric  juice  and  special  evidence  from  the  quantity  and 
quality  of  detritus  and  epithelia  found  in  the  lavage.  Examination 
of  the  blood  for  secondary  anemia  and  signs  of  cancer  and  the  exclusion 
of  proof  of  pus-processes  should  be  done.  Signs  of  anemia  due  to  the 
cachexia  of  old  cases  are  present.  Treatment  medicinally  directed 
to  the  gastric  disturbance,  is  an  element  of  proof,  and  surgically  aimed 
at  exploration  or  removal  of  the  mass  is  the  final  detail  of  diagnosis 
even  when  the  tumor  cannot  be  felt  easily  through  the  abdominal 
wall. 

Enlargement  of  the  liver,  more  usually  new  growth  than  cirrhosis  in 
differentiation  from  renal  disease,  is  often  difficult  of  recognition.  The 
history  of  new  growth  is  often  barren  of  details  except  indefinite  diges- 
tive disorders,  discomfort,  and  irregular  shooting  pains.  In  cirrhosis, 
syphilis  may  be  admitted  and  alcoholism  with  attendant  digestive 
derangement  apparent.  The  subjective  symptoms  are  hepatic  dis- 
order, biliousness  and  jaundice  which  sooner  or  later  sometimes  occur 
with  piles  and  other  intestinal  disorders  through  venous  obstruction. 
Pain  when  it  appears  is  apt  to  be  constant  and  nagging  and  cachexia 
marked.  Objectively,  if  the  enlargement  is  general  or  extensive  it 
changes  the  whole  organ  and  pushes  it  downward,  but  if  local  its  position 
and  relation  may  be  nearly  normal.  Radiography  may  show  definite 
increase  in  the  liver  shadow  at  one  or  more  points  and  the  patient  does 
not  complain  of  any  urinary  disturbance  or  disorder.  Urologic  investi- 
gation is  required  because  the  element  of  pain,  however,  is  in  the  general 
region  of  the  kidney.  The  three  standard  steps  of  cystoscopy,  ureteral 
catheterization  and  functional  test  should  be  carried  out,  and  result 
negatively.  In  the  laboratory  analysis  of  the  mixed  urine  in  the  bladder 
and  of  the  separated  specimens  shows  healthy  kidneys  and  that  of  the 
blood  is  free  of  signs  of  pus  production,  but  sooner  or  later  shows  the 
anemia  of  cancer  and  in  cirrhosis  often  a  positive  Wassermann  test. 
Treatment  by  exposure  of  the  liver  locates  and  measm-es  the  neoplasm 
and  syphilitic  treatment  may  benefit  cirrhosis  and  thus  the  diagnosis 
be  completed. 

Inflammation,  calculus  or  neoplasm  of  the  gall-bladder  much  resembles 
the  findings  of  the  history  just  given  for  the  liver  itself.  Inflammation 
and  calculus  are  apt  to  give  a  rapid  onset  while  neoplasm  has  a  slower 
onset  and  then  the  invasion  of  any  one  of  the  three  may  be  followed  by 


ISC     COMFLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

active  and  severe  sufferings,  in  the  subjective  s\in])t()nis  of  deranged 
(.ligestive  function,  l)oth  gastric  and  intestinal.  -lauudice  is  freciuent 
and  anemia  with  emaciation  not  nnconnnon.  (Jail-stone  colic  is  intense, 
characteristic  and  debilitating.  Objectively,  cachexia  suggests  cancer 
and  a  tumor  or  thickening  in  the  region  of  the  ninth  rib  ])oints  to  the 
gall-bladder.  A'-ray  often  fails  but  nuiy  show  the  shadow  of  stones  or 
neoplasm.  The  only  element  })ointing  to  the  kidney  is  the  location 
of  the  pain  and  of  the  enlargement  as  the  gall-bladder  corresponds 
rather  well  with  the  upper  border  of  the  right  kidney.  There  are, 
however,  only  negati\'e  findings  on  urological  analysis  of  the  case  by 
cystoscopy,  ureteral  catheterization  and  functional  test.  Laboratory 
specimens  of  blood  contain  bile,  and  signs  of  anemia  or  neoplasm  and 
all  those  of  the  urine  are  negative.  INledicinal  treatment  is  usually  of 
little  ^-alue  in  the  diagnosis  which  is  fully  established  by  laparotomy 
and  appropriate  steps  with  the  stones,  inflammation  or  neoi)lasm. 

Subphrenic  (ibscc<s-s  and  perinephriiic  abscess  are  infections  and  may 
closely  simulate  in  history  the  onset  of  infection  of  the  kidney.  Each 
has  respectively  an  hepatic  and  a  renal  syndrome,  either  because  the 
abscess  arises  directly  from  one  in  the  liver  or  the  kidney  or  because 
of  the  accumulation  of  pus  in  direct  relation  with  these  organs.  As 
sym])toms,  subjecti^•ely  there  occur  chills,  fever,  sweats,  changes  in 
pulse,  prostration  and  confinement  to  bed.  Pain  is  severe,  throbbing 
and  localized  in  the  character  typical  of  pus  foci.  Objectively,  in 
general,  depression  of  the  liver  as  a  whole  suggests  sub])hrenic  accumu- 
lation of  the  pus  while  a  mass  in  the  loin,  especially  if  without  the  form 
of  the  kidney  or  its  consistency  or  with  the  prominence  of  the  kidney 
upon  its  surface  displaced  to  the  front,  suggests  a  perinephritic  focus 
of  the  pus.  Physical  examination  will,  therefore,  usually  indicate  the 
site  of  the  difficulty,  which  in  liver  cases  is  cleared  vip  by  aspiration 
below  the  folds  of  the  pleura  and  in  renal  cases  by  cystoscopy,  ureteral 
catheterization  and  functional  test.  If  these  are  negative,  aspiration 
may  be  cautiously  attempted  but  only  by  an  expert  familiar  with 
kidney  landmarks  and  the  general  anatomy  of  the  parts.  In  the 
laboratory  the  blood  count  shows  leukocytosis  and  the  urine  is  negative 
unless  abscess  of  the  kidney  has  been  antecedent.  Treatment  after 
pus  has  been  proved  present  can  be  only  surgical  and  aspiration  is 
deficient  and  incision  and  drainage  alone  adequate. 

Xeoplasni  of  the  kidney  may  have  an  insidious  onset  and  be  practically 
without  special  history,  but  usually  there  are  prodromal  signs  such  as 
discomfort  and  consciousness  that  somethmg  is  wrong  with  the  kidney. 
SjTuptoms,  subjectively,  may  begin  with  the  sudden  increase  of  any 
or  all  of  the  indefinite  feehngs.  Hematuria  of  the  symptomless  type 
may  direct  attention  to  the  kidney,  accompanied  by  pus  and  pain 
without  there  having  been  any  antecedent  focus  of  pus,  pyogenic 
disease,  chills,  fe\'er  or  prostration.  Pain  in  the  sense  of  severe  agony 
is  rare  until  the  disease  is  far  advanced.  Sense  of  weight,  blood,  pus, 
polyuria,  oliguria  and  colic  from  ))lood  or  pus  clots  are  typical.  Sudden 
blood  may  be  the  first  symptom  and  weakness  and  emaxiiation  later. 


URETERITIS,  PYELITIS  AND  PYELONEPHRITIS  187 

Examination  shows  in  the  early  stages  a  normal-looking  patient  with 
cachexia  advancing  with  the  disease.  The  kidney  may  be  slightly 
or  much  enlarged  without  or  with  tenderness,  often  hardened  and  if 
pus  has  appeared  somewhat  difficult  to  distinguish  any  other  pyogenic 
disease  of  the  kidney.  The  colon  percusses  in  front  of  the  tumor. 
Cystoscopy  and  ureteral  catheterization  in  the  early  period  may  be 
negative  unless  made  during  the  bleeding  which  at  once  indicates  the 
diseased  organ  with  possibly  changed  function.  The  .r-ray  may  show 
enlargement  on  the  afl'ected  side.  In  the  laboratory  separated  urines 
may  be  normal  or  one  redundant  with  blood  and  other  changes,  such 
as  albumin,  decreased  urea,  pus,  epithelia,  casts,  fragments  of  tissue 
or  ulcer  and  bacteria.  Blood  smears  and  count  usually  eliminate  pus 
processes  but  indicate  secondary  anemia  and  cancer  if  the  case  is 
developed  far.  Surgical  treatment  as  an  exploratory  or  remedial 
operation  by  removal  of  the  kidney  settles  the  diagnosis. 

New  growth  of  the  colon  with  its  digestive  disturbances,  especially  of 
the  intestinal  tract,  in  the  history,  proceeding  to  constipation,  then 
obstipation  with  ribbon-like  or  scybalous  stools,  requires  attention. 
The  chief  complaints  are  intestinal  discomfort,  augmenting  to  pain, 
indigestion  with  constipation  just  described,  sometimes  alternating 
with  diarrhea,  masked  or  free  bleeding  and  later  emaciation.  Examina- 
tion shows  a  mass  in  the  colon  over  the  kidney  and  without  any  bowel 
in  front  of  it,  often  movable,  slightly  as  the  colon  is,  with  in  some  cases 
dilatation  proximal  to  it  and  atrophy  distal  to  it.  The  colon  may  be 
followed  in  both  directions  from  and  continuous  with  the  tumor. 
The  a--ray  with  a  bismuth  meal  will  show  the  constriction  by  the  tumor 
and  the  condition  of  the  bowel  each  side  of  it  and  its  relation  with  other 
organs.  Cystoscopy,  ureteral  catheterization  and  functional  tests  are 
all  negative.  In  the  laboratory  mixed  urine  taken  from  the  bladder 
or  collected  by  separation  is  negative.  The  stools  contain  fragments 
of  mucous  membrane,  blood  from  the  cancer  and  mucopus  from  the 
colitis  always  present  rather  early.  Blood  smears  have  no  leukocytosis 
as  of  pus  in  acute  foci  but  show  signs  of  anemia  and  cancer.  Treatment 
by  extraperitoneal  or  intraperitoneal  exploration  and  removal  settles 
the  anatomical  diagnosis,  although  clinical  decision  is  certain  without  it. 

Retroperitoneal  growths  have  indefinite  lumbar  pains,  discomfort 
and  enlargement,  in  their  history,  as  prominent  factors  and  in  their 
subjective  symptoms  urinary  and  intestinal  signs  are  absent  until  the 
neoplasm  causes  displacement  and  pressure  rather  than  obstruction. 
Likewise  by  pressure  sometimes  neuritis  of  the  hmibar  nerves  causing 
referred  pains  and  muscular  spasm  are  seen.  Objectively,  the  tumor 
may  be  shown  independent  of  either  kidney,  the  colon  or  other  abdomi- 
nal organs  and  present  only  in  the  loin  or  side.  Cachexia  appears  in 
old  cases.  X-ray  without  the  bismuth  meal  outlines  the  tumor  and 
with  the  bismuth  meal  separates  it  from  the  colon  and  with  collargol 
or  other  opaque  substance  in  the  ureter  and  pelvis  distmguishes  it 
from  the  kidney.  The  bladder  is  normal  on  cystoscopy  and  the 
ureters  and  kidneys  on  functional  test.     In  the  laboratory  m'inalysis 


188     COMPLICATIONS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

of  bladder  and  separated  urines  is  negative  and  investigation  of 
stools  negative  for  blood  and  tissue.  The  blood  count  shows  no 
active  pus  processes  and  may  develop  the  changes  of  anemia  and 
cancer  in  advanced  cases.  Treatment  by  oi)eration  avails  in  the  final 
anatomical  proof  by  removal  of  the  mass  and  later  pathological 
in\'estigatioh. 

Treatment  of  Gonococcal  Acute  and  Chronic  Ureteritis,  Pyelitis  and 
Pyelonephritis. — Gono'-occal  acute  and  cln-oiiic  ureteritis,  })yelitis  and 
pyelonephritis  are  in  their  significance  indubitably  major,  clinically  in 
the  severity,  prognostically  for  the  patient  and  therapeutically  often 
leading  to  important  o])erations. 

Prophylaxis  is  indirect  in  the  i)roper  care  of  anteroposterior  urethritis 
which  prevents  extension  into  the  bladder.  Suitable  measures  in 
cystitis  focalize  the  inflammation  there  from  ascending  the  ureters. 
Prompt  relief  of  pus  foci  as  in  the  prostate,  seminal  vesicles  and  their 
comi)lications  pre^'ents  hematogenous  and  lymphogenous  involvement 
of  the  kidneys  followed  by  the  bladder  by  descent  after  jjrevious 
escape.  Abortion  is  nil.  Early  symptoms  of  ascent  from  the  bladder 
are  indistinguishable  from  the  symptoms  of  cystitis  and  the  hema- 
togenous and  lymphogenous  forms  are  so  sudden  that  no  diagnosis  is 
possible  permitting  abortive  measures. 

Requisites  for  the  management  are  given  in  the  Chapter  on  General 
Principles  of  Treatment  on  page  4S3. 

Curative  Treatment. — In  reaching  these  cases  the  underlying  condi- 
tions must  be  understood.  The  physical  measures  in  acute  periods 
contraindicate  massage  but  later  it  is  a  substitute  for  muscular  exer- 
cise when  generally  applied  and  should  not  be  locally  employed  on 
the  kidney.  This  dictrmi  does  not  include  incidental  massage  of  an 
infected  kidney  to  bring  down  pus  during  a  cystoscopic  examination. 
Xo  aggra^'ation  of  symptoms  must  follow  any  massage. 

The  hydrotherapy,  locally,  stops  all  urethral  treatment  and  similarly 
vesical  irrigation,  both  in  the  acute  stage  but  resumes  them  in  the 
declining  and  terminal  period.  Cold  with  the  ice-cap  and  heat  with 
the  electric  pad  or  properly  applied  poultices  or  hot  sitting  baths 
all  decongest  and  promote  comfort.  General  hot  packs  and  baths  are 
indicated  as  eliminants  in  the  acute  periods  when  urine  is  deficient 
and  as  corrigents  in  incipient  uremia.  In  the  ambulant  periods 
Tm-kish  baths  if  well  borne  are  of  great  value  in  relief  of  the  kidney 
tension  and  should  be  taken  two  or  three  times  a  week  if  possible. 

The  application  of  light  except  with  the  arc  light  in  the  specialist's 
office  is  of  less  value  to  kidney  and  ureteral  conditions  than  to  other 
more  superficial  complications.  It  acts  as  a  decongestant  and  seda- 
tive in  the  acute  period  and  may  help  in  the  resorption  through  actinic 
influence.  In  general,  like  hydrotherapy,  it  is  much  more  convenient 
to  ai)ply  and  a  \evy  good  alternate  for  modified  influence. 

The  electrotherapy  comprises  diathermy  or  the  direct  d'Arson^•al 
current  with  one  plate  over  the  kidney  zone  in  front  and  the  second 
plate  over  the  kidney  zone  behind.    The  intensity  is  200  to  500  milli- 


URETERITIS,  PYELITIS  AND  PYELONEPHRITIS  180 

amperes  of  current,  the  duration  thirty  minutes,  the  frequency  is  three 
times  a  week  and  the  action  is  hyperemia  of  the  orj^an  in  cc^inlwt  with 
the  infection  somewhat  like  the  ]3ier  treatment  in  arthritis  an(]  shows 
the  results  of  increase  tissue  resistance  and  local  metabolism.  A  series 
of  twenty  treatments  is  advisable  with  a  rest  of  two  weeks  between 
during  which  heliotherapy  is  employed  as  adjuvant  and  corrigent. 

The  medicinal  measures  in  the  acute  period  all  support  against 
depreciation  and  prostration  and  are  indicated  by  systemic  adminis- 
tration as  familiar  stimulants,  digestants,  eliminants,  diuretics  and 
urinary  antiseptics.  In  the  chronic  stage  anemia  and  other  results  of 
deficient  kidneys  receive  treatment. 

The  serum  therapy  is  practically  useless  in  the  acute  lesions  but  in 
the  late  stages  if  the  negative  phase  is  carefully  not  produced  in 
marked  form  there  is  response  in  active  immunity  in  a  few  cases  to 
autogenous  or  heterogeneous  or  mixed  bacterins,  notably  Van  Cott's. 
Small  doses,  slowly  ascending  always  within  tolerance  and  repeated 
every  five  to  seven  days,  are  the  rule,  as  described  in  the  section  on 
this  subject  in  Chapter  IX  on  General  Principles  of  Treatment,  on 
page  483.  The  serum  in  inducing  passive  immunity  may  be  disregarded 
in  these  lesions. 

In  the  local  treatment  urethral  lesions  are  left  alone  in  the  acute 
period  exactly  as  in  all  the  other  complications  so  that  no  irrigations 
or  injections  are  permissible.  The  bladder  had  best  not  be  invaded, 
if  possible,  during  the  acme  and  should  otherwise  be  managed  like  a 
cystitis,  as  described  on  page  173.  The  benefits  of  retrojection  .should 
be  secured  at  each  lavage.  In  the  subacute  and  chronic  periods, 
therefore,  all  the  measures  available  in  cystitis  become  possible  and 
applications  through  the  cystoscope  to  the  bladder  are  not  of  least 
importance  combined  with  lavage  of  the  pelvis  and  ureter.  The  prin- 
ciples of  such  irrigations  are  the  same  as  those  defined  for  all  mucosae 
— gentleness  in  passing  the  instruments  and  mild  solutions  at  first 
followed  by  slow  ascent  in  strength  to  avoid  traumatism  and  irrita- 
tion. It  is  well  to  use  small  ureter  catheters  first  for  ease  of  the  return 
flow  without  spasm  or  distention.  Sterile  w^ater  or  other  cleansing 
agent  should  be  used  first  followed  by  nitrate  of  silver  which  is  the 
best  in  from  1  in  1000  to  1  in  100  concentration.  Argyrol  3  to  10  per 
cent.,  collargol  3  to  10  per  cent,  and  protargol  0.5  to  1  per  cent,  are 
also  available.  The  technic  of  this  procedure  is  given  in  Chapter  XIII 
on  Cystoscopy,  on  page  734. 

Antecedent  urethritis  may  be  treated  through  the  cystourethroscope 
in  the  manner  described  under  that  subject  on  page  647. 

The  nonoperative  surgical  measures  are  defined  by  the  occasional 
retention  of  urine  due  to  reflex  inhibition  as  catheterism  with  the 
single  passage  or  the  indwelling  catheter  according  to  mdications  to 
avoid  frequent  entrance  into  the  bladder.  The  other  nonoperative 
procedures,  such  as  irrigations,  instillations,  retrojections  and  dila- 
tations obviously  belong  to  the  urethra  and  bladder,  as  already  described 
for  these  sites. 


190      COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

The  operative  surgical  measures  devote  themselves  to  couditions 
beyond  ordinary  measm-es.  In  the  minor  operations  the  posterior 
m-ethritis  is  treated  by  urethroscopy  and  the  cystitis  by  cystoscopy, 
described  on  page  80G,  each  antecedent  to  the  ureteritis  and  nephritis 
and  after  the  declining  period  of  the  latter  two,  they  are  also  subse- 
quent to  them  and  require  treatment  usually  to  avoid  relapse  and  new 
extension  upward. 

By  catheterization  of  the  ureters  is  made  diagnosis  of  ureteral  and 
kidney  conditions,  evacuation  of  accumulated  exudate  and  cleansing 
and  stinuilation  of  the  mucosa — all  in  the  methods  described  under 
this  subject  in  the  Cha])tcr  on  Cystoscopy  on  i)agc  S2(). 

Among  the  major  operations  arc  drainage  of  the  kidney,  nephrotomy 
and  nephrectomy  in  the  order  of  their  severity,  both  as  to  cause  and 
nature.  Exposiu'e  of  the  kidney  for  each  is  the  same  so  that  it  is 
best  to  describe  the  technic  for  nephrectomy  first. 

Nephrectomy  may  be  done  by  several  methods:  (1)  Lmnbar,  (2) 
paraperitoneal,  (3)  transperitoneal  and  (4)  morcellation.  In  sup- 
puration of  the  kidney  the  lumbar  route  is  preferred  and  will  therefore 
alone  engage  oiu*  attention.  The  paraperitoneal  method  consists 
briefly  in  opening  the  loin  rather  anteriorly  and  in  turning  back  toward 
the  opposite  side  the  entire  peritonemn  with  its  contents  until  the 
kidney  is  reached.  The  transperitoneal  is  the  abdominal  method  and 
in\'olves  opening  the  peritoneal  cavity,  isolating  its  contents  with 
pads  and  reaching  the  kidney  through  the  parietal  layer  over  it,  which 
after  vertical  division  is  turned  outward  and  inward  for  access  to  the 
kidney  and  its  pedicle.  jMorcellation  is  removal  of  the  kidney  in 
small  pieces  either  from  within  its  fibrous  or  its  fatty  capsule  accord- 
ing to  circmnstances. 

The  selection  of  case  requires  a  kidney  which  is  se\erely  damaged 
and  its  function  on  urinalysis  and  catheterization  of  the  ureters  either 
profoundly  altered  or  abolished.  The  instnmients  and  supplies  are 
assorted  scalpels,  various  scissors  with  blunt  points,  long  and  short 
and  straight  and  curved  blades,  assorted  long  forceps  without  and 
with  teeth,  hemostats  and  ligatiu'es,  abdominal  retractors  with  narrow 
and  wide  and  long  and  short  blades,  several  pedicle  clamps  with 
curved  and  angle  jaws,  right  and  left  and  right-angle  aneiu-ysm  needles 
or  other  ligature  carriers,  needle-holders  with  assorted  needles  includ- 
ing intestinal  needles,  sutures  of  catgut,  silk  and  silkworm  gut,  cigarette 
drains  and  standard  dressings.  The  preparation  of  the  patient  and 
field  are  standard  and  include  a  wide  area  from  the  hip  to  the  nipple 
and  two-thirds  around  the  body  and  the  anesthesia  is  generally  pre- 
ferably with  gas  and  oxygen  as  the  first  choice  and  gas  and  ether 
as  the  second  choice  or  local  acjording  to  advanced  methods  of  injec- 
tion and  infiltration.  Braun-Shields^  says:  "  Kappis  recommends 
simple  paravertebral  conduction  anesthesia  without  the  concomitant 
circuminjection.     For  this   pm'pose   the   eighth   dorsal   to   the   first 

1  Local  Anesthesia:  Its  Scientific  Basis  and  Practical  Use,  1914,  p.  322. 


URETERITIS,  PYELITIS  AND  PYELONEPHRITIS  191 

lumbar  nerves  must  be  blocked;  for  operations  on  the  ureter,  the 
second  and  third  lumbar  nerves  must  also  be  blocked."  He  also  states 
that  "since  the  development  of  this  method  almost  all  kidney  opera- 
tions are  performed  under  local  anesthesia  at  the  Kiel  clinic." 

The  posture  provides  the  following  details:  Utmost  extension  of 
the  iliocostal  space;  full  freedom  of  respiration;  absence  of  pressure 
or  constriction  by  sharp  edges;  security  against  shifting  or  slipping  of 
the  body;  protrusion  oif  the  kidney  into  the  wound  by  pressure  from 
in  front.  Various  tables  with  kidney  attachments  and  separate  devices 
such  as  Edebohls's  bag  are  recommended,  with  preference  for  the 
tables  because  they  are  secure  against  slipping  and  permit  change  of 
position  by  more  or  less  elevation.  The  landmarks  are  the  vertebral 
column  in  the  middle  line  with  the  border  of  the  erector  spinse  muscle, 
the  twelfth  rib  above  and  the  crest  of  the  ilium  below  setting  off  the 
iliocostal  space. 

The  incisions  are  variously  placed:  (1)  Vertical,  parallel  with  the 
outer  border  of  the  auadratus  lumborum  muscle;  (2)  oblique,  from  about 
the  center  of  the  twelfth  rib  downward  and  outward  to  the  anterior- 
superior  spine  of  the  ilium,  ending  midway  between  this  prominence 
and  the  umbilicus;  (3)  transverse,  passing  just  below  the  tips  of  the 
twelfth  and  eleventh  ribs  horizontally  forward  from  the  erector  spinse 
muscle;  (4)  rectangular  or  Koenig's  incision  combining  the  vertical 
with  a  more  or  less  horizontal  forward  incision  from  its  lower  extremity 
just  above  the  crest  of  the  ilium;  and  (5)  combined,  in  which  any  two 
of  the  foregoing  incisions  are  variously  united  to  gain  space,  usually  the 
transverse  (3)  with  one  of  the  other  forms.  The  vertical  incision  is 
one  of  the  most  common  and  passes  through  the  skin,  fat  and  fascia 
between  the  middle  of  the  twelfth  rib  and  the  crest  of  the  ilium  in  the 
superficial  field,  reaching  above  the  latissimus  dorsi  fibers  directed 
upward  and  outward  toward  the  shoulder  and  below  the  oblique 
externus  fibers  running  downward  and  forward  toward  Poupart's 
ligament  as  the  first  muscular  layer.  After  severing  these  it  exposes 
above  and  then  divides  the  serratus  posticus  inferior  fibers  directed 
upward  and  outward  between  the  spine  and  the  rib,  and  reveals  below, 
then  cuts  the  obliquus  internus  fascicles  directed  upward  and  outward 
toward  the  middle  line  of  the  body  as  the  second  muscular  layer. 
Along  the  mesial  border  of  the  incision  lies  the  sheath  of  the  erector 
spinse  which  remains  unopened,  and  across  its  lower  portion  is  the 
ilioinguinal  nerve  which  should  be  protected  by  retraction.  This 
exposes  the  deep  layer  of  the  lumbar  aponeurosis.  Division,  thereof, 
along  the  entire  length  of  the  skin  incision  enters  the  deep  field  upon 
the  quadratus  lumborum  muscle  either  at  the  inner  margin  or  bottom 
of  the  wound  forms  either  retraction  inward  or  separation  of  its  fibers 
to  the  trans versalis  fascia  and  fat  beneath  it.  Separation  of  these  with 
the  fingers  or  by  blunt  dissection  frees  the  peritoneiun  which  with  the 
colon  is  retracted  toward  the  abdomen  and  carefully  padded  and 
further  separation  reaches  the  kidney. 

The  oblique  incision  is  preferred  by  the  author  because  extension 


192     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

downward  gives  access  to  the  ureter.  It  begins  at  the  midpoint  of  the 
twelfth  rib  and  ends  just  above  the  anterior  superior  spine  in  corre- 
spondence with  the  <hrection  of  the  ol)Hquns  extcrnus  fibers,  for  blunt 
separation  and  not  sharp  diA'ision  along  their  course.  The  cut  may 
be  lengthened  to  and  even  across  the  sheath  of  the  rectus  abdominis 
for  very  wide  ex])osm-e  in  the  paraperitoneal  a]i]>roach  of  the  ureter 
or  downward  toward  the  s>in])hysis  pubis  for  reasonable  access  to 
the  bladder.  In  the  iliocostal  space  the  general  planes  passed  dupli- 
cate those  given  for  the  vertical  incision. 

The  resection  of  the  twelfth  rib  is  often  practised  subperiosteally 
in  order  to  gain  space,  about  two  inclies  of  the  rib,  often  including  its 
tip  being  rcn\oved  and  division  of  the  costovertebral  ligaments  is  a 
less  radical  step  for  the  same  purpose.  The  pleura  often  dips  below 
the  rib  and  must  be  spared. 

The  cautions  of  the  incision  are  the  ilioinguinal  nerve,  peritoneum, 
colon,  pleura  and  the  sheath  of  the  erector  spina^.  The  iliohypogastric 
nerve  is  sensory  and  may  be  divided  if  encroaching  on  the  upper  part 
of  the  wound  but  the  ilioinguinal  is  partly  motor  and  must  be  spared 
in  the  lower  portion.  The  peritoneum  and  pleura,  if  woimded,  should 
be  carefully  closed  with  banked  Lembert  sutures  and  the  bowel  simi- 
larly managed,  if  damaged.  Invasion  of  the  sheath  of  the  erector 
spina^  is  of  little  importance  except  that  it  opens  another  plane  of 
possible  infection  and  should,  therefore,  be  avoided  by  keeping  lateral 
to  its  border. 

The  separation  of  the  kidney  is  digital,  if  the  fat  is  healthy  and 
soft,  and  by  blunt  dissection  if  the  fat  is  diseased  and  adherent  and 
must  reach  complete  exposure  imless  the  fatty  capsule  is  to  be  removed. 
Presenting  parts  are  first  approached  and,  therefore,  in  the  anatomical 
terminology,  the  lower  pole,  posterior  surface,  outer  border,  anterior 
surface,  upper  pole,  mesial  border,  hilum  and  pedicle  in  the  order  given 
are  liberated. 

The  cautions  of  the  separation  are  aberrant  vessels  in  resistant 
strings  of  fat  requiring  division  between  double  ligatures  and  adhe- 
sions about  the  pedicle  denoting  doulile  mass  ligatures  or  penetration 
with  the  aneurysm  needle  and  ligature  in  sections.  Either  method  is 
followed  by  terminal  ligature  of  each  vessel  as  it  presents  in  the  cut 
end  of  the  pedicle. 

The  delivery  of  the  kidney  upon  the  loin  is  easy  and  safe  provided 
the  vessels  are  not  too  short  ancl  that  the  perinephritis  has  not  been  so 
dense  as  to  fix  the  kidney  pedicle  and  that  the  patient  is  not  so  fat  as 
to  materially  increase  the  distance  from  the  great  vessels  to  the  surface. 
The  organ  must  reach  the  skin  with  little  or  no  traction,  otherwise 
shock  is  certain  iind  tearing  of  large  trunks  probable  with  hemorrhage 
hardly  equalled  elsewhere  in  the  body  and  at  the  bottom  of  a  deep  and 
inaccessible  wound. 

The  isolation  of  the  pedicle  rests  on  the  anatomical  fact  that  the 
pelvis  is  most  posterior  and  lowest  of  the  structures  at  the  hilum. 
Hence  the  finger  hooked  around  the  structures  below  the  lower  pole 


URETERITIS,  PYELITIS  AND  PYEWNEPIIRfTIS  193 

will  embrace  the  ureter,  which  may  })e  easily  separated  witli  another 
finger  or  blunt  scissors,  while  either  the  kidney  is  turned  backward 
toward  the  skin  and  inward  toward  the  spine  or  its  lower  pole  elevated 
for  slight  tension  on  the  ureter.  Digital  or  blunt  instrumental  dis- 
section of  the  ureter  should  be  carried  downward  quite  to  the  brim 
of  the  pelvis.  The  ureter  may  be  found  against  the  parietal  peri- 
toneum, as  it  is  held  out  of  the  way  toward  the  middle  line  of  the  body, 
through  adhesions  to  the  serosa  and  with  the  general  direction  over  the 
outer  border  and  anterior  surface  of  the  psoas  magnus  muscle.  The 
tube  should  be  liberated  from  the  brim  of  the  pelvis  to  the  kidney  and 
then  the  pelvis  of  the  ureter  is  freed  first  posteriorly,  then  its  lower  and 
upper  borders  and  finally  its  anterior  surface  if  the  fat  is  healthy,  but  if 
hardened  with  infection,  dissection  is  stopped  practically  at  the  lower 
pole  of  the  kidney.  Thus  the  vessels  are  brought  into  view  with  the 
artery  in  the  middle  and  the  vein  in  front  in  typical  cases  but  often 
the  bifurcations  are  atypical.  Division  between  double  ligatures  of 
the  ureter  as  far  down  as  possible  is  the  next  step  with  cauterization 
of  both  stumps  with  carbolic  acid  and  alcohol,  thermocautery  or 
electrocautery.  The  distal  stump  is  advisedly  stitched  to  the  subcuta- 
neous fascia  near  the  lower  angle  of  the  wound  for  ready  reach  in  case 
of  secondary  remote  trouble  with  it.  The  proximal  stump  may  be 
used  as  a  tractor  on  the  kidney  and  a  guide  to  the  vessels  of  the  pedicle 
with  judgment  and  gentleness. 

After  isolation  of  the  pedicle  in  degree  according  to  pathologic  con- 
ditions, a  renal  pedicle  clamp  is  placed  across  it  next  to  the  kidney 
and  closed  tight  enough  to  stop  circulation  but  not  to  cut  through 
the  veins.  Further  separation  of  the  vessels  may  be  possible.  A 
ligature  is  passed  proximal  to  the  clamp,  that  is,  between  the  aorta 
and  vena  cava  and  the  clamp,  but  not  so  close  to  the  great  vessels  as 
to  slip  through  pulsation  and  pressure  or  so  near  the  clamp  as  to  slip 
through  too  short  a  stump.  When  the  ligature  is  seen  to  close  the 
vessels  fully,  as  tied,  the  kidney  is  cut  free  and  removed  and  the  mouth 
of  each  vessel  gaping  in  the  end  of  the  stump  is  seized  with  artery 
clamp  and  ligated  for  safety. 

The  cautions  of  removal  refer  to  the  dissection  and  the  ligation.  As 
to  cautions  of  dissection  one  notes  that:  (1)  the  pelvis  should  not  be 
minutely  freed  at  the  pedicle  amid  adhesions  but  the  ureter  should 
be  tied  low  down  and  (2)  free  extension  of  the  mcision  downward  and 
inward  is  required  for  full  management  of  the  ureter. 

As  to  cautions  of  ligation  oiie  defines  that:  (1)  the  ureter  is  doubly 
ligated,  divided  and  both  stumps  cauterized;  (2)  clamps  are  closed 
only  to  stop  bleeding  without  risk  of  cutting  or  tearing  through  the 
veins  of  the  pedicle;  (3)  vessels  are  ligated  between  the  clamp  and  the 
body  and  not  between  the  clamp  and  the  kidney,  that  is,  proximally 
and  not  distally;  (4)  vessels  are  ligated  during  relaxation  and  not  dur- 
ing tension  or  traction;  (5)  adherent  pedicles  are  best  ligated  twice 
in  mass  or  twice  in  halves  in  mass  if  transfixion  is  possible  rather  than 
after  dissection  of  individual  vessels,  which  usually  tears  the  veins; 
13 


194      COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETIIRITIS 

(6)  clamps  may  be  left  on  pedicles  too  tough  to  1)0  llgated  and  removed 
in  four  or  live  days;  (7)  division  of  the  vessels  is  made  aAvay  from  the 
clamp  for  proper  lengtli  of  stump  against  slipping  of  the  ligature; 
(S)  all  exposed  mouths  of  vessels  in  the  stump  should  be  indi^■idually 
ligated. 

The  drainage  to  the  stiunp  of  the  ureter  and  pedicle  and  pocket  of 
the  ui)i)er  pole  is  proN'ided  with  cigarette  druins  reaching  the  surface 
at  the  lowest  angle  of  the  wound,  after  careful  toilet  of  the  cavity.' 
Suture  of  the  planes  of  fascia  and  muscle  is  carefully  done  do^^^l  to 
the  drains  and  the  skin  is  closed  with  silkworm  gut  e^•ery  inch  or  less. 
A  very  large  dressing  should  be  ai)])lied  in  layers  and  protected  by  a 
many-tail  or  ordinary  abdominal  binder,  so  as  to  permit  frequent 
removal  during  the  period  of  free  oozing  of  pus,  serum  or  blood. 

Ajiertreatmeni. — The  immediate  aftertreatment  respects  the  wound 
and  the  other  kidney.  As  to  the  womid  the  dressing  should  be 
inspected  every  ten  minutes  during  the  first  hour  and  at  longer  inter- 
vals during  the  first  day  for  secondary  hemorrhage  or  undue  oozing. 
The  dressing  should  be  changed  down  to  the  deepest  layer  in  the  later 
case  and  again  watched  at  brief  intervals  in  order  to  be  siu-e  that  the 
oozing  is  checked.  The  drains  are  replaced  as  soon  as  loose  and  those 
from  the  pedicle  are  last  disturbed.  The  stitches  are  cut  out  from  the 
seventh  to  the  tenth  day  and  if  clamps  were  left  on  the  pedicle  they 
are  slightly  loosened  on  the  fourth  day  and  removed  on  the  fifth  or 
sixth  day. 

As  to  the  other  kidney,  the  aim  is  to  promote  its  increased  function. 
The  diet  should,  therefore,  be  antinephritic  and  salt-free  until  the 
organ  is  known  to  be  fully  competent.  In  the  earlier  convalescence 
the  ^lurphy  drip  one  hour  on  and  one  hour  off  or  proctoclysis  a  pint 
at  a  time  is  a  good  stimulant.  Hot  packs  in  severe  cases  are  essential 
and,  if  well  borne,  will  often  tide  the  patient  over  the  dangers  of  acute 
uremia. 

As  to  the  antecedent  urethritis  and  cystitis  proper  aftertreatment 
requires  their  cure  along  the  lines  described  under  each,  otherwise 
either  or  both  will  remain  as  foci  of  relapse  or  reinfection.  These 
lesions  are  therefore  of  great  importance  in  the  full  restoration  of  the 
patient. 

The  remote  aftercare  continues  drainage  and  dressing  of  the  wound 
along  strictly  surgical  lines  so  that  in  from  four  to  eight  weeks  the 
cavity  should  be  closed  without  sinus.  Nursing,  diet  and  medication 
are  according  to  indications  and  frequent  urinalysis.  The  remaining 
kidney  is  protected  by  warning  the  patient  against  any  errors  leading 
to  congestion  or  other  disturbance,  such  as  excesses  in  diet,  drink, 
exercise  and  exposure.  After  several  months  if  the  kidiiey  is  found  to 
be  secreting  normal  urine  the  ordinary  conditions  of  life  may  be 
resumed. 

Cure  implies  a  healed  wound  without  sinus  or  other  sequel  and  a 
normal  kidney  on  the  opposite  side.  Nature  may  be  slow  in  supplying 
the  second  detail  so  that  the  remote  aftercare  is  usually  extremely 


URETERITIS,  PYEIJTIS  AND  PYELONEI'II h'lTIH  195 

important.  Pathologically,  cure  of  the  kidney  by  rerriovul  is  impos- 
sible but  of  the  less  affected  orp;an  is  the  expected  result  and  the  relief 
from  the  danger  in  a  destroyed  and  infected  organ  is  obvious.  Syrnp- 
tomatically,  cure  is  restoration  of  the  opposite  kidney  from  signs  of 
overwork,  congestion  and  perhaps  early  inflammation  or  infection  to 
full  and  normal  function  and  bacteriologieally  the  absence  of  organisms 
in  the  urinary  system  is  in  gonococcal  complications  entirely  essential. 

Nephrotomy  is  a  much  less  severe  operation  than  nephrectomy  and 
in  a  certain  sense  exploratory  in  the  selection  of  case  of  severe  lu'etero- 
pyelitis,  pyelonephritis,  calculus,  abscess  of  the  kidney  or  perinephric 
abscess.  All  preliminaries  are  the  same  as  for  nephrectomy,  including 
preparation  of  the  patient  and  field,  incision,  superficial  and  deep 
fields,  isolation  of  the  kidney  and  its  delivery  on  the  loin. 

The  examination  of  the  kidney  includes  palpation,  needling,  fluoros- 
copy, control  of  hemorrhage  and  penetration.  As  to  palpation,  the 
delivered  kidney  is  supported  on  the  palmar  surfaces  of  the  fingers 
passed  about  its  pedicle  and  then  the  opposite  hand  in  regular  order 
examines  the  ureter,  pelvis,  calyces  and  parenchyma,  from  upper  to 
lower  pole  and  from  hilum  to  free  border  for  irregularities  of  surface 
and  consistenc}'^,  indm-ation  and  tension,  fluctuation  and  calculus.  The 
retained  kidney  in  the  depth  of  the  wound  may  be  felt  in  the  same 
systematic  but  less  thorough  manner  when  it  cannot  be  delivered. 

As  to  needling  or  multiple  puncture  of  the  kidney  for  similar  diagnosis 
it  should  be  said  that  the  method  is  no  longer  in  favor  except  in  verifica- 
tion of  definite  points  detected  by  palpation.  It  is  not  reliable,  rather 
unsafe  and  best  omitted  but  does  not  include  aspiration  of  suspected 
abscesses  with  a  needle  and  syringe.  It  consists  in  stabbing  the  paren- 
chjona  one  or  two  dozen  times  through  and  through  with  a  needle, 
aiming  to  strike  any  pathological  focus,  especially  stones. 

As  to  fluoroscopy,  much  may  be  learned  by  having  a  good  .r-ray 
machine  in  the  operating  room  and  the  portable  hand  screen  available 
with  which  the  kidney  and  pelvis  delivered  on  the  loin  are  inspected 
for  infiltrations  and  stones. 

As  to  control  of  hemorrhage,  one  recognizes  prevention  and  relief. 
The  prevention  implies  compression  of  the  vessels  to  avoid  the  bleeding 
in  a  mobilized  and  delivered  kidney.  Digital  or  rubber  guarded  clamp 
compression  is  available,  just  to  stop  the  circulation  and  always 
without  traumatism  of  the  vessels.  The  best  clamps  have  rather  thin 
jaws  which  meet  first  at  the  tips  and  gradually  spring  together,  per- 
mitting the  pedicle  to  be  seized  in  the  free  interval  and  gradually 
compressed  while  the  tips  of  the  jaws  steady  the  blades.  The  control 
requires  tampon  or  suture.  Tamponade  of  the  wounded  kidney  is 
unreliable  but  often  unavoidable  when  the  organ  is  fixed  in  the  wound 
and  cannot  otherwise  be  reached.  Firm  pressiure  with  the  outer  di-ess- 
ing  under  adhesive  plaster  passing  two-thirds  around  the  body  and 
frequent  inspection  for  signs  of  failm-e  of  the  packing  must  not  be 
omitted.  Suture  is  much  more  reliable  and  comprises  two  lines  or  one 
line  of  mattress  stitches  always  of  plain,  never  of  chromic  gut,  without 


196     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

constriction,  dimplini;  or  lividity  of  the  orpin  within  thv  bi<,'ht  of  the 
ligature. 

As  to  penetration  of  the  kidney  for  digital  or  instrumental  explora- 
tion, a  cut  is  made  at  the  junction  of  the  lower  and  middle  thirds, 
about  a  quarter  inch  ])osterior  to  the  vertical  niidi)lane.  is  carried  into 
the  ])el\is  in  dt>pth  and  then  enlarged  to  admit  the  little  or  the  index 
finger,  which  should  easily  reach  all  the  cavities  of  the  pelvis.  Splitting 
of  the  kidney  from  end  to  end  may  be  performed  for  wide  exposure, 
diagnosis  or  removal  of  pathological  foci.  Single  abscesses  are  incised 
over  their  most  ])romincnt  dependent  ])oint  and  stones  removed  by 
access  on  the  same  i)rinciplc.  Calculi  in  the  ])elvis  may  be  removed  by 
p>'elotomy — division  of  the  wall  foUowed  by  removal  of  the  stone  and 
banked  suture.  Drainage  of  the  kidney,  as  in  pyelitis,  hydronephrosis 
and  ]\vonei)hrosis  is  accomplished  by  reduction  of  the  mass  of  the  dis- 
tended organ  through  e^■acuation  with  the  aspirating  needle  or  trochar 
and  cannula,  then  by  penetration  of  the  pelvis  as  just  noted  combined 
with  gentle  breaking  down  of  all  minor  pockets  into  one  major  cavity 
and  finall>-  by  suturing  into  the  mouth  of  the  kidney  wound  with  very 
fine  plain  catgut,  one  or  two  ^•elvet-eye,  soft-rubber  catheters  leading 
from  depths  of  the  cavity  through  the  lower  ])art  of  the  kidney  to  the 
skin.  Patency  of  the  lu-eter  should  be  proved  with  ureteral  catheters 
and  other  instrmnents  before  the  operation  is  ended. 

The  suture  of  the  kidney  brings  the  hahes  of  the  divided  organ  or 
the  lips  of  the  wound  together  gently  with  two  or  one  layer  of  mattress 
sutures  always  without  constriction.  The  deep  and  sui)crficial  fields 
are  closed  with  layer  sutures  in  the  fascia  and  muscle  planes  down  to 
the  drains  emerging  at  the  lower  part  of  the  skin  incision,  closed  with 
silkworm  gut  sutiu-es. 

The  cautions  of  nephrotomy  are:  ( 1)  Padding  against  infection  of  the 
planes  and  pockets  of  the  wound  during  the  operation;  (2)  drainage 
against  retention  in  the  recovery;  (3)  proof  of  patency  of  the  ureter; 
(4)  removal  of  offending  stones,  masses  and  the  like;  (o)  control  of 
hemorrhage  with  packing  or  suture;  (6)  drainage  of  the  kidney,  pelvis 
and  cavity  as  needed;  and  (7)  restoration  of  the  kidney  to  its  bed  as 
nearly  as  possible  in  its  normal  relations  to  avoid  kinks  or  other  com- 
pression of  the  ureter. 

Aflcrlreatment. — Immediate  steps  require  regular  cleansing  of  the 
tubes  into  the  pelvis;  irrigation  of  this  cavity  with  sterile  water,  nitrate 
of  silver  1  per  cent,  or  arg\Tol  10  per  cent.;  renewal  and  shortening 
of  the  cigarette  drain  when  loosening  at  the  end  of  about  a  week; 
frequent  renewal  of  dressings  for  cleanliness  against  pus  and  for  proof 
of  hemorrhage  during  the  first  day.  Nursing,  diet  and  medication  are 
those  recognized  for  any  type  of  inflanunation  of  the  kidney.  Stimu- 
lation of  the  skin  relieves  the  congestion  of  the  kidneys  should  reflex 
oliguria  or  anuria  arise. 

Cure,  pathologically,  so  that  the  afl'ected  kidney  is  fully  normal 
probably  ne^'er  occurs,  but  its  physiology  may  be  restored  to  normal 
by  the  surgical  treatment  of  affected  points  in  the  removal  of  concre- 


ACUTE  RETENTION  OF  URINE  197 

tions,  either  or  both,  followed  by  compensatory  hypertrophy.  This  is 
symptomatic  cure  and  is  the  exy)e(;ted  result  in  most  cases  and  in 
particular  many  ureterites  and  i^yelites  which  have  not  involved  the 
mucous  membrane  seriously  and  have  not  com])roniised  tli(;  kidney 
beyond  severe  congestion  and  without  true  infection  or  inflammation, 
Bacteriologically  in  gonoccocal  .disease  relief  from  the  y^resence  of  this 
organism  is  most  important  and  one  cannot  speak  of  cure  while  it  is 
present  on  smear  and  culture  and  while  the  positive  complement 
fixation  test  persists. 


ACUTE  RETENTION  OF  URINE. 

Definition. — Acute  retention  of  urine  may  be  described  as  inability 
to  evacuate  the  bladder,  due  to  conditions  within  and  about  the  urethra 
locally  or  within  the  central  nervous  system  symptomatically  leading  to 
muscular  spasm  and  paresis  rather  than  to  paralysis.  As  a  complica- 
tion of  gonococcal  acute  urethritis^  it  is  not  to  be  confounded  with 
the  retention  of  stricture  of  the  urethra,  hypertrophy  and  neoplasm 
of  the  prostate  and  organic  nervous  disease. 

Etiology. — The  causes  of  acute  retention  as  indicated  in  the  defini- 
tion are  local,  that  is,  urethral,  as  periurethral  and  centric  or  nervous. 
The  urethral  factors  are  edema  and  spasm  of  the  sphincter.  Within 
the  urethra  the  edema  of  the  mucosa  may  be  inherent  in  the  severity 
of  infection  or  arise  from  irritation  by  instrumentation,  alcoholism, 
food,  sexual  excess,  exposure  and  exertion  which  may  similarly  cause 
spasm  of  the  sphincter  by  their  direct  irritation.  The  spasm  may  also 
be  of  reflex  spinal  origin  through  the  inhibition  of  such  complications 
as  gonococcal  acute  prostatitis  and  seminal  vesiculitis.  Outside  the 
urethra  by  direct  obstruction  or  by  the  same  reflex  influence,  prosta- 
titis, seminal  vesiculitis  and  cowperitis  may  be  elements.  The  centric 
or  nervous  factors  are  seen  chiefly  in  the  acute  complications  within  the 
cerebrospinal  axis,  which  go  with  severe  absorptive  septic  types  and 
are  chiefly  nem*itis,  meningitis  and  myelitis.  They  lead  to  temporary 
paresis  or  spasm,  as  a  rule. 

Varieties. — Retention  of  lu-ine  during  a  gonococcal  infection  in 
clinical  classification  is  acute,  occurring  during  an  acute  or  declining 
urethritis;  and  relapsing,  appearing  during  exacerbations  of  gono- 
coccal chronic  urethritis  or  during  chronic  hypertrophy  of  the  prostate. 
The  latter  w^ill  be  more  fully  discussed  under  these  subjects.  The 
retention  of  organic  cerebrospinal  disease  does  not  concern  this  work. 

Symptoms.— The  patient  shows  in  his  subjective  history  sudden 
inability  to  void  urine  at  all  for  a  longer  or  shorter  time  or  only  in  a 
few  drops  at  each  potent  effort.  Distention  of  the  bladder  causes 
excruciating  agony.  The  objective  signs  are  a  bladder  which  is  well 
above  the  s\^uphysis  pubis  on  palpation  and  percussion,  protected  by 
muscular  rigidity  and  a  urethra  obstructed  by  any  of  the  periurethral 
or  endourethral  causes.    Centric  nervous  cases  give  their  o^-n  peculiar 


198     COMI'JJCATJLLW'S  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

picture  as  iHscussed  later  in  Clia])ter  TTI  under  Centric  Nervous  Com- 
plications on  ])age  2',\\). 

Diagnosis.  Acute  retentit>n  of  urine  is  considered  only  with  its 
relation  to  urethritis  and  must  have  in  its  history  the  elements  of 
obstruction,  edema,  muscular  spasm,  traumatism  or  excesses  as  to 
the  urethra  or  the  factors  of  i)ressure  and  sjiasm  from  ])r()statitis  and 
\esiculitis  as  to  periurethral  conditions.  The  history  of  centric  nervous 
disturbance  in  brain  or  cord  followed  by  acute  retention  of  urine  is 
foreign  to  our  subject.  Obviously,  if  central  ner\'ous  disease  is  sug- 
gested by  the  case  in  addition  to  the  urethral  infection,  full  neurological 
investigation  for  sensory,  motor,  reflex  and  trophic  changes  in  the 
nerves  and  for  signs  of  cerebral  disease  must  be  carried  out.  The  chief 
complauits  are  inability  to  urinate  at  all  or  only  slightly,  with  pain 
and  the  shock  or  prostration  of  overdistention.  Objectively,  the 
bladder  palpates  and  percussess  far  aboN'c  the  symphysis  and  projects 
downward  into  the  rectum.  Urethral  i)ali)ation  often  develops  the 
site  and  nature  of  the  obstruction.  Tlie  laboratory  must  show^  infec- 
tious material  w'ithin  the  urethra,  most  commonly  gonococcal  but 
rarely  any  of  the  other  organisms  causing  urethritis  and  fully  dis- 
cussed under  that  subject.  Kelief  of  the  obstruction,  m  the  treatment, 
settles  the  source  of  the  trouble  and  the  diagnosis  and  suitable  meas- 
ures directed  to  the  urethritis  or  its  complications  pre^•ent  relapse 
and  likewise  aid  in  the  proof  of  the  exact  form  of  retention. 

Treatment. — Gonococcal  acute  retention  of  urine  is  in  its  significance 
usually  minor  if  reflex,  as  during  the  in\'asion  of  severe  acute  forms  of 
posterior  m'cthritis,  prostatitis  and  seminal  vesiculitis  but  is  major 
if  obstructive  as  is  seen  in  stricture  of  the  urethra  and  prostatic  or 
other  periurethral  abscess. 

Prophylaxis  is  indirect  and  applied  to  attention  to  the  causes  by 
avoiding  the  sources  of  edema  of  the  urethra  and  irritation  by  instru- 
mentation, alcoholism,  improper  food  and  drink,  indirect  and  direct 
sexual  excitement  and  physical  exertion.  Sedatives  should  quiet 
early  reflex  inhibition  in  posterior  urethritis,  prostatitis  and  seminal 
vesiculitis.  Earl\'  diagnosis  and  treatment  of  pressure  by  extraurethral 
pus  are  preventives  of  major  retention.  Abortive  measures  relieve 
the  edema  by  active  hydrotherapy  in  hot  penile,  sitting  and  body 
baths,  by  reliable  sedatives  such  as  morphin  and  bj^  evacuation  of  pus 
accumulations  in  any  of  the  periurethral  structures. 

The  reader  will  note  the  necessary  particulars  in  Chapter  IX  on 
General  Principles  of  Treatment  on  page  483. 

Curative  Treatment. — Physical  measures  are  hardly  available.  Until 
relief  of  the  retention  massage  is  impossible,  but  then  valuable  for 
such  antecedents  as  prostatitis.  Hydrotherapy  is  active,  especially 
hot  urethral  irrigations  with  adrenalin  solutions  1  in  1000,  rectal 
irrigation  with  hot  normal  salt  solution  through  the  double  current 
tube  or  the  prostatic  cooler,  and  sitting  baths  hot  until  the  skin  is 
made  very  red.  They  all  relieve  the  congestion  and  edema  and  fre- 
quently the  retention  so  that  the  patient  may  evacuate  his  urine  into 


ACUTE  RETENTION  OF  URINE  199 

the  sitting  bath.  Vesical  irrigation  is  of  value  in  cases  dependent  in 
cystitis.  General  baths  eliminate  and  relieve  the  kidneys  and  Turkish 
baths  are  more  efficient  in  cases  dejjendent  on  kidney  involvement. 
Hot  packs  are  added  for  the  same  purpose.  The  heliotherapy  requires 
a  500  C.P.  therapeutic  lamp  very  warm  but  not  too  hot  moving  steadily 
about  over  the  field  and  applied  up  to  intense  redness  of  the  skin  but 
without  pain  or  blister  affecting  the  lower  abdomen,  lower  perineum 
and  back.  Its  results  are  the  decongestion  by  profound  hyperemia  and 
the  relief  by  diaphoresis. 

The  medicinal  measures  are  sedative  for  the  reflex  nervous  element 
by  systemic  administration  including  morphin  and  codein  and  their 
allies  unless  contraindicated  by  nephritis.  Urinary  diluents  and  neu- 
tralizers  of  recognized  types  soothe  the  entire  urinary  tract  and  elimi- 
nants  and  diuretics  are  available  in  kidney  cases.  Urinary  antiseptics 
combat  the  infection  and  probably  no  combination  is  better  for  its 
urinary  influence  in  all  respects  than  the  following  formula  whose 
elements  are  both  adjuvants  and  corrigents  of  each  other: 

I^ — -Hexamethylenamin 7.5  grains  (0 . 5  gramme) 

Benzoate  of  soda 7.5  grains  (0 . 5  gramme) 

Qistilled  water  up  to 1  dram    (4.0  c.c.) 

Mix,  make  a  solution  and  mark: 

Take  one  teaspoonful  every  four  hours,  with  a  glass  of  water,  or  three  times  a  day , 
two  hours  after  eating,  as  improvement  occurs. 

By  local  administration  the  bladder  is  evacuated  with  the  catheter, 
as  subsequently  stated,  and  much  benefit  results  from  the  instillation 
of  a  few  drops  of  nitrate  of  silver  solution  1  per  cent,  or  2  per  cent., 
which  reduces  the  edema  and  congestion  and  often  quickly  controls 
the  infection  on  which  these  rest.  The  quantity  instillated  must  be 
only  2  or  3  drops  otherwise  damage  and  not  benefit  will  ensue.  All 
other  local  measures,  such  as  irrigations,  hand  injections  and  instru- 
mentations, are  necessarily  stopped  until  the  tendency  to  retention 
has  disappeared.  The  surgical  measures,  nonoperatively,  include  the 
use  of  a  small  velvet-eye  soft  rubber  or  a  soft  lisle-thread  catheter  very 
gently  passed  into  the  bladder  after  previous  irrigation  of  the  urethra 
with  very  hot  normal  salt  solution  containing  adrenalin  1  in  1000, 
followed  by  irrigation  of  the  bladder.  In  the  nature  of  retention  leaving 
the  antiseptic  fluid  in  the  bladder  for  evacuation  and  retrojection  of 
the  urethra  cannot  be  employed  until  the  patient  begins  to  urinate 
even  imperfectly.  Retention  catheters  are  used  for  the  more  severe 
cases  but  always  with  hesitation  and  on  the  least  sign  of  irritation  with 
instant  removal  because  their  foreign  body  action  makes  the  underhdng 
condition  worse.  Irrigation  of  the  bladder  through  such  retention 
catheter  is  both  possible  and  necessary.  Operatively  evacuation  of 
pus  accumulation  in  periurethral  structures  is  preeminent,  such  as 
Cowper's  glands,  the  prostate  and  sometimes  the  seminal  vesicles. 
The  operations  are  described  under  each  heading.  Cure  of  stricture 
of  the  urethra  as  a  frequent  underlying  cause  is  imperative. 


200       (VMI'LICATJOXS  AXD  SEQUELS  OF  ACUTE  UREriilUTIS 

Aficrtrcdtnirnt.- — Tlu>  iiiimoiliato  aftertrratiiUMit  is  to  soothe  and 
quiet  the  bhulder  witli  urinary  secUitive  dihients  and  antiseptics  and 
also  the  nervousness  of  the  patient  reflexly  and  mentally  aiiri  remotely 
is  to  alleviate  the  antecedent  and  consequent  conditions  both  medical 
in  the  urethritis  and  cystitis  and  sur^it-al  in  abscesses  and  stricture. 

Cure,  path()logicall\',  must  respect  the  underlying  bases  and  so  far 
as  the  retention  is  concerned  should  be  complete  but  so  far  as  damage 
of  the  urethra  and  its  annexa  is  concerned  may  be  very  incomplete, 
as  already  demonstrated  under  the  pathology  of  eacli  lesion.  Symp- 
tomatically  relief  of  the  retention  is  absolute  either  through  catheterism 
or  operation  followed  by  SN'stemic  and  local  medication  for  the  infec- 
tion whose  bacteriologic  destruction  is  essential  for  cure. 


CHAPTER   III. 

COMPLICATIONS  AND  SEQUELS  OF  ACUTE  UUETHP.mS. 

((Jo7itinved.) 

COMPLICATIONS    OF   POSTERIOR    GONOCOCCAL   ACUTE 

TJRETHmTIS.—iContimied.) 

B.  Extragenital  or  Systemic  Group. 

Clinical  Importance. — The  gonococcus  with  its  toxins  may  invade 
all  systems  of  the  body  with  complications  which  are  the  constitu- 
tional, systemic  or  extraurogenital  manifestations.  These  compli- 
cations will  be  discussed  under  the  name  of  the  system  involved,  as 
in  the  following  subdivisions. 

Varieties.^Cutaneous,  digestive,,  circulatory,  respiratory,  central 
nervous,  special  sensory  and  locomotory  complications  are  seen,  each 
respecting  its  own  system. 

1.  Cutaneous  Complications. 

Occurrence. — The  skin  is  not  often  affected  but  somewhat  more  in 
males  than  females  and  usually  in  the  severe  persistent  gonococcal 
infections  during  other  complications  with  absorption  and  toxemia. 
The  occurrence  of  drug  rashes  during  such  cases  makes  it  important 
to  eliminate  these  as  the  possible  lesions.  The  end  of  the  first  month 
is  the  common  date  of  appearance.  Their  relation  to  the  gonococcus 
and  the  toxins  must  be  elucidated.  Their  clinical  importance  is  rela- 
tively little. 

Varieties. — Penile  cutaneous  folliculitis,  condylomata  acuminata, 
erythema,  purpura  and  keratoses  are  most  often  seen.  The  first  two 
are  the  most  common  and  important.  Their  significance  marks  most 
of  them  as  immaterial,  especially  folliculitis,  er3i:hema,  purpura  and 
keratoses  on  account  of  their  rarity  and  occasional  difficulty  of  identi- 
fication with  the  gonococcal  involvement;  but  condylomata  acuminata 
are  important. 

General  Diagnosis. — The  reader  is  referred  to  books  on  diseases  of 
the  skin  because  more  than  outlines  in  this  work  would  be  redundant. 
A  cutaneous  complication  during  a  gonococcal  m-ethritis  or  its  com- 
plications must  be  more  than  a  coincidence.  There  must  be  absorp- 
tion and  circulation  in  the  blood  of  the  gonococci  or  their  toxins  in 
order  to  link  the  manifestations  in  the  skin  with  the  infection. 

Treatment. — The  lesions  are  cured  along  dermatological  principles 
in  soothing  applications  during  acute  irritation  followed  by  stimula- 


202     COMPLICATION'S  'ax6  SEQUELS  OF  ACUTE  URETHRITIS 

tioii  during  iiululcnt  and  chronic  stages — combined,  of  course,  with 
relief  from  the  j^rincipal  focus  of  absorption.  Full  details  are  referred 
to  works  on  Perinatology. 

CONDYLOMATA    ACUMINATA. 

Synonyms. — Cantrell  and  Stout'  give  the  following  list:  Pointed 
wart;  moist  wart;  fig  wart;  cauliflower  excrescence;  verruca  elevata; 
venereal  wart;  Ger.  Spitzencondylom,  Spitzenwarze;  Fr.  Vegetations 
dermiques. 


Fig.  53. — Condylomata  acuminata,  confluent  form.  Extensive  condylomata  acu- 
minata of  gonococcal  origin  filling  the  entire  corona  and  preputial  fold  extending  far 
forward  on  the  glans  on  the  right  side  as  far  as  the  frcnuni.  Preputial  excoriations  were 
present  on  the  left  side  but  do  not  show  in  the  photograph.     (Author's  case.) 

Definition. — These  are  warts  or  true  papillomata  usually  of  venereal, 
not  infreciuently  of  nonvenereal  origin,  afl'ccting  the  modified  skin 
commonly  over  the  glans  and  within  the  foreskin  of  the  male,  less 
commonly  the  cutaneous  sheath  of  the  penis,  and  over  the  external 
and  internal  labia  and  even  the  thighs  of  the  female.  The  nonvenereal 
origin  of  these  warts  is  important,  otherwise  unjust  suspicion  will  be 
lodged  against  the  innocent.  Extragenital  situations  for  these  papil- 
lomata are  the  anus,  axillse,  umbilicus  and  interdigital  folds  of  the  toes. 

1  An  American  Text-book  of  Genito-urinary  Diseases,  Syphilis  and  Diseases  of  the 
Skin.     Bangs  and  Hardaway:  1899,  p.  956. 


COND  YLOMA  TA  A  C  UMINA  TA 


20.: 


Etiology.— Tendency  to  warts  is  definitely  known  and  is  a  predispos- 
ing cause  of  the  lesions  under  discussion.  It  is  well,  therefore,  to  look 
for  other  papillomata,  on  the  hands,  for  example,  especially  when  the 
case  may  be  nonvenereal.  Another  predisposing  factor  is  retention, 
decomposition  and  irritation  of  the  smegma,  thus  repeating  the  con- 
ditions of  apposition,  excoriation,  moisture,  warmth  and  retention  of 
perspiration  in  the  extragenital  forms.  Added  to  these  elements  in 
the  venereal  cases  is  the  gonococcal  infection  with  its  penetrating, 
proliferating  influence  and  in  the  nonvenereal  cases,  the  microorgan- 
isms of  the  skin.  That  warts  may  be  infectious  is  suggested  by  the 
case  of  Payne,  quoted  by  Cantrell  and  Stout,'  who  after  having  removed 
a  wart  with  his  nail  had  one  develop  beneath  the  same  nail. 


Fig.  54. — Intraiiretliral  warts.  The  mass  entirely  filled  the  meatus,  causing  a  high 
degree  of  obstruction.  They  did  not  extend  far  up  the  canal  so  that  removal  with  scissors 
was  easy.     (Author's  case.)  , 


Pathology. — As  in  all  other  warts,  the  essence  of  the  process  is  pro- 
liferation of  the  papillary  layer  of  the  cerium  and  thickening  and 
cornification  of  the  epidermis  with  increase  of  connective  tissue  and 
vascularity.  The  cells  of  the  rete  are  highly  developed  while  the 
horny  layer  is  scantily  changed.  Without  treatment  the  warts  are 
permanent  lesions,  and  increase  in  size  and  number  to  remarkable 
limit.  After  removal  no  material  scars  persist.  The  associated  lesions 
are  regularly  the  gonococcal  urethritis  in  acute,  declining  or  chronic 

1  Log.  cit. 


204     COMPLICATIONS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

stage  and  the  balanoposthitis  which  both  causes  and  is  produced  by 
the  warts.  Occasionally  these  lesions  are  found  within  the  meatus  as 
well  :is  in  the  situations  noted  undt>r  definition. 

Symptoms. — The  warts  themselves  by  their  actual  presence  and 
tlischarge  in  retractible  foreskins  are  the  only  subjective  sjinptoms, 
but  in  irretractible  foreskins  the  irritation  of  the  discharge  from  the 
chronic  relapsing  l)alano])osthitis  is  the  chief  conii)laint.  The  objec- 
tive signs  are  in  the  loose  foreskins  under  the  eye  or  in  the  tight  fore- 
skins through  a  urethroscopic  tube  the  papillomata  themsehes,  which 
are  like  the  cock's  comb  or  cauliflower,  usually  pedunculated  but  less 
connnonly  sessile,  vascular,  from  j)inhead  to  lima-bean  size,  with  a 
yellowish  foul  discharge  or  slimy  crust.  Subpreputial  irrigation  must 
be  done  in  tight  foreskins  before  a  full  examination  can  be  made.  The 
termination  of  these  warts  is  indefinite  persistence  with  relapsing 
balanoposthitis  unless  removed  by  treatment  and  their  clinical  signifi- 
cance is  that  tlie  sodden  condition  of  the  parts  which  they  uiduce  is 
a  direct  avenue  for  syphilitic  infection. 

Diagnosis. — Common  warts  on  the  finger  during  childhood,  ecze- 
matous  and  nonresistant  conditions  of  the  skin  are  frequent  admis- 
sions in  the  history  proving  a  tendency  of  the  patient  to  papillary 
hypertrophy,  to  which  is  added  the  irritation  of  the  gonococcal  jjus 
especially  in  folds  of  the  skin  of  the  prepuce  in  the  male  and  the  \'ulva 
in  the  female.  Subjective  symptoms  are  the  flow  or  drop  of  pus  from 
the  urethra  or  vulva,  furnishing  the  infection  of  the  foreskin  in  man 
or  pudendum  in  woman,  followed  by  the  gradual  or  rapid  develop- 
ment of  the  warts  in  scattered,  confluent  or  general  distribution. 
Objective  examination  ^'erifies  the  presence  of  the  warts  and  the  causa- 
tive pus  and  determines  their  features  as  similar  to  a  cock's  comb, 
sessile  or  pedunculated  and  foully  odoriferous  and  accompanied  by  the 
chronic  drop  and  excoriating  balanoposthitis  or  vuhitis.  In  the 
laboratory  by  smear  or  culture  the  infectiousness  of  the  ])us  is  pro^-ed 
as  often  due  to  the  gonococcus  alone  and  equally  often  to  other  organ- 
isms commonly  found  in  the  skin,  associated  with  the  gonococcus  or 
independent  of  it.  Section  of  a  wart  determines  its  benign  character, 
while  treatment  is  easy  remoA'al  with  caustic,  knife  or  electric  spark 
leaving  behind  no  infiltrated  base,  thus  p^o^'ing  its  simple  N'errucous 
nature.  Relief  of  the  urethritis,  balanoposthitis  or  ^'ulvitis  pre^'ents 
relapse  and  again  shows  the  lesion  to  be  noncancerous. 

Differential  Diagnosis  is  concerned  with  syphilitic  condyloma,  includ- 
ing the  moist  papules  of  the  secondary  stage  of  syphilis,  and  malignant 
neoplasm. 

Condyloma  latum  differs  from  acvmmatvvi  hi  always  being  associated 
with  syphilis  in  one  of  its  periods,  usually  the  secondary,  less  com- 
monly the  tertiary  stage.  A  careful  history,  therefore,  elicits  the  fact 
of  secondary  or  tertiary  syphilis  with  the  development  of  the  condy- 
loma or  positive  blood  tests  may  be  admitted  with  the  chief  complaint 
of  a  painless,  moist  sore  under  the  foreskin  or  within  the  folds  of  the 
vulva  with  thin  watery  or  blood-stained  discharge  and  without  any 


.  CONDYLOMATA  ACUMINATA  205 

other  sensation  except  occasional  ardor  urina;  if  urine  touches  one. 
Examination  shows  a  broad,  sessile,  fissured  exuberant  growth  never 
pedunculated  in  its  attachment,  with  a  serous,  serosanguinolent  or 
seropurulent  discharge  from  which  the  Treponema  pallidum  may 
commonly  be  recovered.  Characteristic  cord-like  lymphatic  trunks 
and  bean-like  or  shot-like  lymphatic  glands  are  always  present.  'J'he 
laboratory  determines  the  organism  of  syphilis  in  the  discharge  and  in 
the  tissue  whose  sections  exclude  malignant  neoplasm.  Treatment 
with  mercurials,  locally  and  interjially,  c;ombined  with  the  iodides 
or  with  the  newer  arsenical  compounds  is  of  immediate  and  corrobora- 
tive efi^ect  and  diagnostic  proof. 

Neoylasm  differs  from  condyloma  acuminatum  in  the  age  of  the 
patient,  through  its  history  and  in  its  onset  under  entirely  different 
circumstances  from  those  of  infection.  Cardinal  symptoms  describe 
a  growth  under  the  foreskin  or  within  the  folds  of  the  vulva  of  an 
ulcerous,  painful,  infiltrating  mass  often  accompanied  early  with 
involvement  of  the  lymphvessels  and  glands.  All  the  symptoms  of 
chronic  phimosis  and  chronic  balanoposthitis  are  common  antecedents. 
Examination  on  exposure  of  the  growth  reveals  the  infiltration,  raised, 
hardened  edges  and  bleeding  surface  of  an  epithelioma  with  hardened 
l^mphtrunks  and  glands  connected  with  it.  The  laboratory  rules 
out  infection  with  gonococci  or  the  Treponema  pallidum  and  in  the 
section  of  tissue  develops  the  neoplastic  character,  while  all  measures 
of  treatment  along  the  line  of  stimulation  and  cauterization  fail  to 
heal.  Excision  of  the  penis  or  a  wide  portion  of  the  vulva  along  with 
•  the  glands  affected  finishes  the  diagnosis  by  submitting  the  specimen 
to  the  laboratory. 

The  following  case  report  of  condylomata  acuminata  in  an  infant 
of  remarkable  degree  is  given  by  R.  R.  Smith. ^  No  gonococci  were 
demonstrated  in  the  discharge. 

It  is  seldom  that  so  luxiu-iant  a  growth  of  condylomata  is  seen  as 
the  following  case: 

B.  S.,  infant,  aged  nineteen  months.  Mother  states  that  neither 
parent  has  had  syphilis  to  her  knowledge,  but  she  had  had  gonorrhea 
nine  months  before  the  child  was  born,  but  without  discharge  at  the 
time  of  birth.  Child  always  w^ell  except  for  occasional  diarrhea  and 
without  discharge  or  irritation  about  the  genitals  within  mother's 
observation.  Apparently  wdthin  three  months  the  entii*e  growth  as 
presented  in  the  photograph  developed,  beginning  on  one  labium.  Fair 
nourishment,  paleness,  normal  teeth  and  no  skin  lesions  or  scars  of 
lesions  w^ere  noticed  on  examination.  The  growth  about  the  ^Tilva  is 
demonstrated  by  the  illustration.  The  growth  was  remoA^ed  siu-gi- 
cally  and  the  diagnosis  of  condyloma  acuminatmn  was  made  by  a 
pathologist.     No  gonococci  were  discovered. 

Treatment. — Both  prophylaxis  and  abortion  apply  in  all  then-  general 
principles. 

1  Am.  Gynec,  1903,  II,  iii,  515. 


206     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

Curative  Trcaimcni. — I'sually  all  relief  fails  unless  the  antecedent 
gonococcal  chronic  urethritis  is  relieved,  because  removal  of  the  warts 
will  be  followed  by  relapse  unless  the  irritation  of  the  discharge  is 
absent. 


Fig.  55. — Condyloma  acuminatum  in  a  child,  aged  nineteen  niontns. 
(Case  of  Dr.  R.  R.  Smith.) 

Curative  measures  have  the  following  details  and  are  all  important: 
The  management  is  the  same  as  that  in  any  other  gonococcal  chronic 
disease  and  physical  methods  come  to  the  fore  with  fulguration  of  the 
warts  with  the  high  frequency  current  of  Oudin,  representing  electro- 
therapy in  this  field  and  fulfilling  special  service  in  the  condylomata 
of  the  meatus  and  the  urethra.  Its  application  is  simple  with  the 
ordinary  high-frequency  machine  developing  the  current  of  Oudin. 
The  spark  gap  is  from  one-twelfth  inch  to  one-eighth  inch  and  the 
switch  is  usually  half  open.  Local  anesthesia  may  be  ajiplied  but  is 
not  absolutely  necessary.  The  cm-rent  is  applied  until  blanching  or 
mild  blackening  occurs  which  is  followed  in  a  few  days  by  the  shedding 
of  the  lesions.  As  a  rule,  a  few  are  treated  at  each  sitting  until  all  are 
remo\ed. 

[Medicinal  measures  consist  in  drying  powders  applied  to  the  field  of 
this  or  other  operation  and  occasionally  to  the  warts  themselves  if 


CONDYLOMATA  ACUMINATA 


207 


they  are  few  and  scattered.  They  keep  the  base  of  the  wound  clean 
and  prevent  moisture  from  which  these  lesions  proceed.  A  service- 
able powder  contains: 


0.5  drams  (2 . 0  grarnrnf.s; 


I^ — Calomel, 

Powdered  alum, 

Bismuth  subnitrate,  of  each 

Mix,  make  a  powder  and  mark: 
External  application  as  directed. 

Small  condylomata  acimiinata  may  be  removed  by  painting  them 
with  the  following  solution: 

IJ — Salicylic  acid 0.5  drams  (2 . 0  grammes) 

Glacial  acetic  acid  enough  to  make  a  thin  paste. 
Mix,  make  a  thin  paste  and  mark: 

Apply  to  the  warts  as  directed  until  the  surface  is  white.    The  .surgeon  and  not  the 
patient  should  carry  out  these  applications. 

The  wart  may  be  surrounded  by  a  thin  layer  of  white  vaseline  to 
protect  its  annexa  and  then  the  paste  is -applied  rather  Jiberally  but 
without  flooding  and  with  the  crystals  of  salicylic  acid  worked  into 
the  surface.  Excess  of  acetic  acid  is  removed  with  slips  of  blotting 
paper  and  then  the  application  dries  in  the  air  and  a  small  dressing 
protects  the  lesion,  which  will  drop  off  in  seven  days  or  less.  Several 
warts  may  be  so  treated  at  a  time  until  all  are  removed  with  the  one 
caution  that  the  normal  surfaces  must  not  be  attacked  by  the  solution 
and  that  none  must  be  allowed  to  reach  the  urethra.  Apposed  sur- 
faces are  kept  apart  by  cotton  loosely  packed  in. 

Surgical  measures  deal  at  once  with  underlying  phimosis  and  para- 
phimosis at  the  same  time  that  the  warts  are  clipped  off.  Marked 
growths  are  always  best  removed  under  local  or  general  anesthesia 
with  forceps  and  scissors,  including  their  bases,  followed  by  gentle 
stimulation  with  10  per  cent,  silver  nitrate  solution  to  still  bleeding  and 
prevent  infection.  The  little  wound  is  sutured  if  possible,  and  a  heal- 
ing powder  applied.  Warts  of  the  skin  are  apt  to  be  hard  vegetations, 
easy  of  removal  with  closure  of  the  base,  while  warts  of  the  mucosa 
and  modified  skin  are  a  little  less  easy  of  suture  if  their  bases  are  exten- 
sive. Warts  of  the  meatus  may  be  clipped  off  with  care  not  to  injure 
the  lips  and  with  attention  to  healing  to  prevent  stenosis;  but  like 
these  growths  farther  in  the  canal  the  high-frequency  ciu-rent  of  Oudin 
is  preferred  to  scissors.  Warts  about  the  anus  and  within  the  rectmn 
are  dealt  with  in  exactly  the  same  manner  with  incisions  converging 
toward  the  anus  in  general  correspondence  with  its  normal  folds. 
Through  the  proctoscope  growths  higher  up  may  be  fulgm-ated. 

Aftertreatment. — Sm-gical  dressings  for  cleanliness  and  primary  imion 
are  required.  The  catgut  stitches  are  absorbed.  Secondary  union  is 
usually  without  deep  scar. 

Cure  pathologically  and  s^auptomatically  involves  removal  of  the 
wart  with  its  base,  bacterial  relief  from  infection  and  ablation  of 
offending  foreskin  or  other  underlying  anatomical  cause,  and  these 
lesions  are  regarded  as  annoying  but  not  grave. 


20S     COMPLJCATIUXS  AM)  6KQUELS  OF  ACUTE   URETHRITIS 

2.    Digestive  CovqMcations. 

Occurrence. — When  coin])aral  witli  tionococcal  arthritis,  the  digestive 
manit'estations  are  rare  but  are  imich  more  coiiuiioii  than  tlie  cutaneous 
lesions. 

Varieties.  •  Acute,  subacute  and  chronic  as  to  course  are  tlie  chief 
chnical  forms  which  are  again  sul)(H\"ided  as  to  site  into  buccal,  anal, 
rectal  and  rectoanal.  These  are  rather  connnon,  but  esophageal,  gas- 
tric, intestinal  and  colcmic  are  without  record  in  literature.  Peritoni- 
tis is  seen  occasionally  in  males  but  frequently  in  females. 

Significance.  ~  Stomatitis  and  ])roctitis  usually  occur  by  direct  trans- 
ference of  i)us  and  are  both  obstinate  and  intractable  and  ])eritonitis 
is  a  severe  invalidating  and  not  uucommonly  fatal  condition.  The 
clinical  importance  of  these  complications  is  great  and  of  si)ecial  con- 
cern for  transmission  of  the  disease  to  the  innocent. 

Etiology .^ — Invasion  by  the  gonococcus  is  regularly  the  exciting 
cause,  engrafted  on  absence  of  resistauce  in  the  body  at  large,  or 
locally  through  same  antecedent  disease.  Septicemic  gonococcal 
urethrites  are  a])t  to  have  digestive  complications. 

Diagnosis. — The  jiroof  is  of  imi)ortance  and  is  limited  by  difficulties 
of  cultiu'e  of  the  gonococcus,  both  alone  or  associated  Avith  other 
organisms.  The  gonococcus  dies  easily  in  unfavorable  pabulum  and 
surroundings  and  is  probably  destroyed  by  the  various  digestive 
secretions. 

Treatment. — Exposed  surfaces  are  freed  of  the  infecting  gonococcus 
and  restored  to  as  nearly  normal  as  possible.  Special  surgical  meas- 
ures are  required  in  proctititis  and  peritonitis. 


GONOCOCCAL   STOMATITIS. 

Occurrence. — Bacteriologically  proved  stomatitis  is  rare,  especially 
in  comparison  with  widespread  sexual  perversion.  Prostitution  deter- 
mines a  greater  frequency  among  females  than  males,  and  ophthalmia 
causes  it  among  children  more  than  adults. 

Etiology. — The  gonococcus  is  present  either  by  direct  contact  or  by 
indirect  deposit  during  bacteriemia. 

Pathology. — The  lesions  are  much  the  same  as  in  other  squamous 
ei)ithelial  mucos?e — hypersecretion,  desquamation  and  supi)uration. 

Symptoms. — The  stages  of  invasion,  establishment  and  termination 
designated  by  the  three  pathologic  processes  just  named  are  the  same 
as  elsewhere  in  the  body. 

Diagnosis. — The  gonococcus  must  be  detected  by  smear  and  culture 
and  ill  s('i)tic  cases  the  gonococcal  com})lement  fixation  test  is  required. 

Differential  Diagnosis. — Determination  of  the  cause  distinguishes 
gonococcal  stomatitis  from  simple  acute  and  chronic  inflammations, 
scarlet  fever,  measles  and  typhoid  fever,  diabetes,  syphilis,  scorbutus 
and  metallic  poisoning.  Consultation  with  a  dentist  is  always  advis- 
able. 


GONOCOCCAL  ACUTE  PROCTITIS  209 

Treatment. — Prophylaxis  is  of  the  eyes  and  nose.  Local  antiseptics 
to  destroy  the  infection  followed  by  astringent  and  healing  lotions  and 
proper  care  of  the  gums  and  teeth  by  a  dentist  are  sufficient.  In  septic 
cases  treatment  of  the  primary  focus  is  essential. 

GONOCOCCAL   ACUTE   PROCTITIS. 

Occurrence. — When  compared  with  several  other  complications  of 
gonococcal  acute  urethritis,  rectitis  is  not  often  seen  but  it  is  more 
common  than  ^  stomatitis.  Among  European  authorities,  Jullien^ 
believes  that  it  is  present  in  nearly  5  per  cent,  of  all  cases,  which  is  an 
estimate  far  in  excess  of  experience  in  America.  In  the  Genitourinary 
Clinic  of  the  House  of  Relief  in  New  York  City,  for  seven  or  eight  years 
under  the  charge  of  the  writer,  with  an  average  weekly  attendance  of 
about  150  cases,  very  few  examples  of  it  indeed  were  encountered. 
Taylor-  says:  "This  affection  is  more  or  less  frequently  observed  in 
countries  in  which  sodomy  is  practised  and  it  sometimes  occurs  in 
America."  Full  bacteriological  proof  is  necessary  comprising  the  three 
general  steps  of  smear,  culture  and  complement  fixation  in  order  to 
establish  diagnosis.  It  is  found  more  often  in  female  than  male  adults, 
owing  to  the  incidence  of  prostitution  upon  the  former  sex,  on  the  other 
hand,  however,  so-called  "male  prostitutes"  almost  invariably  have 
it,  likewise  boys  who  have  been  the  victims  of  homosexual  perver- 
sions. 

Varieties. — Acute,  subacute  and  chronic  forms  as  to  clinical  course 
are  recognized  and  as  to  site  anal,  anorectal  and  rectal,  localized  and 
generalized.  The  tendency  of  the  disease  to  become  chronic  renders  the 
mergence  of  the  three  clinical  forms  into  one  more  convenient  for 
description.  Primary  cases  due  to  artifacts  and  secondary  cases  fol- 
lowing other  infections  are  seen.  The  rapid  ascension  from  the  anus 
into  the  rectum  likewise  renders  clinical  subdistinction  unnecessary. 
In  fact,  the  anal  condition  is  prominent  only  in  virtue  of  severe  lesions 
above  this  muscle. 

Etiology. — Penetration  of  the  gonococcus  into  the  rectum  by  con- 
tinuity from  the  anus  or  by  accident  from  instruments  or  fingers  or  by 
sexual  perversion  is  regularly  the  exciting  cause.  Thus  the  entrance 
of  the  organism  is  either  direct  or  indirect.  As  to  indirect  access, 
the  predisposing  factor  in  females  is  gravitation  of  the  pus  from  the 
vulva  and  vagina  upon  the  perineum  and  the  anal  region  in  the  recum- 
bent position,  and  its  pocketing  between  the  nates  and  the  funnel- 
like form  of  the  anus.  The  frequency  of  gonococcal  infection  in  women 
without  anorectal  complications  renders  this  cause  unimportant  and 
almost  inert.  Penetration  within  the  sphincter  ani  muscle  is  also  ren- 
dered difficult  by  tonic  action  which  results  exactly  as  does  the  similar 
state  of  the  sphincter  vesicae  in  preventing  progress  of  the  gonococcus 
into  the  bladder.     Growth  of  the  gonococcus  upon  the  anus  is  also 

1  Rev.  int.  de  med.  et  de  chir.,  1905,  -svi,  109. 

2  Genito-urinary  and  Venereal  Diseases,  3d  edition,  p.  95. 
14 


210     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

liiiulered  b>'  the  sqiianious  ciiitlielium  tliciv,  which  is  poor  soil.  It  is 
probable,  therefore,  that  some  cause  is  always  present  i)lanting  the 
organism  above  the  limits  of  the  muscle. 

As  to  direct  access,  on  which  depend  true  primary  cases,  instrumental 
infection  of,  the  rectimi  with  douche  nozzles  prc\'iously  used  for  the 
^■agina  and  then  for  rectal  cneniata  is  connnon.  The  ^^■riter  had  a 
patient  who  vigorously  washed  his  genitals  clean  of  gonococcal  pus 
with  a  sponge  and  employed  the  same  sponge  at  the  same  sittings  to 
bathe  his  anus,  with  the  result  of  gonococcal  anoproctitis.  The  most 
common  direct  cause  is  sodomy,  intercoiu'se  through,  the  rectiun  or 
coitus  per  anmn.  Less  usual  is  infection  of  the  rectum  from  sinuses 
entering  it  from  extensive  gonococcal  abscesses  of  the  prostate  and 
Cowper's  glands. 

Norris^  notes  "  three  cases  resulting  from  the  rupture  of  a  pyosalpinx 
into  the  rectimi." 

Pathology. — The  lesions  of  proctitis  must  largely  be  inferred  from  the 
behavior  of  the  gonococcus  in  all  other  mucous  membranes.  The 
essence  of  the  process  is  infection  and  penetration  of  the  gonococcus 
into  the  mucosa,  followed  by  temporary  lesions  in  acute  cases,  such  as 
congestion,  edema,  proliferation,  infiltration,  purulence  and  hemor- 
rhage. Tendency  to  chronic  thickenings  in  older  cases  are  seen  as 
permanent  lesions  exactly  as  in  the  urethra,  so  that  the  wall  of  the 
bowel  loses  its  elasticity  and  even  becomes  narrowed.  Likewise 
proliferation  of  the  mucosa  into  condylomata  acimiinata  is  common. 
Associated  lesions  in  the  ischiorectal  fosste  such  as  abscesses  are  seen 
which  proceed  from  associated  organisms  like  the  Bacillus  coli  communis 
and  in  the  wall  of  the  rectmn  as  fibrous  deposits  of  semicartilaginous 
density,  and  if  a  sinus  from  a  periurethral  or  periuterine  complication 
has  preceded  the  rectal  involvement  its  featiu'cs  will  be  obvious.  The 
involvement  is  usually  confined  to  the  terminal  four  inches  but  the 
whole  rectum  may  suffer. 

Symptoms. — The  periods  of  invasion,  establishment  and  termina- 
tion with  subjective  and  objective  findings  may  be  distinguished. 
Compared  with  other  gonococcal  infections  the  subjective  invasion 
is  relatively  little;  Luys-  for  example,  says:  "As  a  rule,  anorectal 
gonorrhea  is  characterized  by  a  complete  absence  of  subjective  symp- 
toms." This  can  be  only  relatively  true  and  the  symptoms  must 
depend  on  the  severity  of  the  inflammation  and  the  comparatively 
less  irritability  of  the  rectiun  than  of  the  urinary  organs. 

On  the  other  hand,  among  older  writers,  Taylor^  and  among  more 
recent  authors  Norris^  describe  marked  and  positive  symptoms  of  the 
disease  corresponding  with  the  writer's  experience. 

Heat  and  discomfort  are  first  seen,  which,  in  the  subjective  estab- 
lishment become  marked  and  are  followed  by  pain,  irritation,  discharge 
and  functional  disorder.  The  pain  is  due  to  the  congestion,  excoriation, 
ulcerations  and  fissures  and  the  stimulation  of  the  bowel  to  empty 

I  Gonorrhea  in  Women,  1913,  p.  396.  ^  Text-Vjook  on  Gonorrhea,  1913,  p.  233. 

'  Log.  cit.  ■•  Loc.  cit. 


GONOCOCCAL  A  C UTE  PROCTJ  TIS  2 1  ] 

itself,  which  may  be  accompanied  by  all  the  irritation  of  general  proctitis. 
The  discharge  is  at  first  a  serous  moisture  not  greatly  apparent  riy)on 
the  anus  but  rather  acconj]:)anying  the  stools,  and  later  be(;omes  puru- 
lent and  even  bloody.  Severe  anal  involvement  is  followed  by  folli- 
culitis, minute  ulcers  and  even  fissures  with  their  spasm  and  tenesmus. 
The  early  irritation  of  defecation  becomes  the  agony  of  proctitis  with 
its  diarrhea  containing  pus  and  sometimes  blood.  Eczematous 
involvement  of  the  anus,  perineum,  thighs  and  buttocks  by  secondary 
infection  of  the  skin  is  complained  of. 

The  objective  symptoms  are  in  suspects  of  sodomy  a  funnel-form 
anus  through  the  unnatural  practice  and  its  force.  The  signs  of  inflam- 
mation may  be  comparatively  little  or  marked,  so  that  frequently 
proctoscopy  and  digital  exploration  are  required  for  diagnosis.  Such 
procedures  the  acute  and  severe  stage  forbids,  but  with  subsidence  of 
suffering  they  may  and  should  be  carried  out.  If  the  anus  is  involved 
it  is  reddened,  edematous,  the  site  of  folliculitis,  ulcers  and  fissures 
and  surrounded  by  a  zone  of  eczema  extending  to  the  perineum,  inter- 
gluteal  fold,  buttocks  and  thighs,  all  bathed  in  a  seropurulent  or  puru- 
lent. Irritating  discharge.  The  sphincter  may  be  relaxed  and  moderate 
prolapse  present.  Venereal  warts  similar  to  those  in  genital  gono- 
coccal infection  are  common.  All  these  conditions  are  repeated  within 
the  rectum  itself.  Jullien^  gives  three  cardinal  symptoms:  the  con- 
dyloma, the  drop  and  the  fissure.  The  condyloma  aciuninatum  is 
pathognomonic  when  about  and  within  the  anus  and  rectum.  It  is 
delicate,  friable,  vascular,  fimbriated  and  pedunculated  or  glossy  and 
sessile  and  usually  covered  with  thin,  slimy  pus.  A  case  in  the  author's 
practice  had  the  warts  of  various  size  and  form  distributed  numerously 
and  universally  over  the  lower  portion  of  the  bowel  for  at  least  iixe 
or  six  inches  and  accompanied  by  the  characteristic  mucopiu"ulent 
discharge  and  perianal  dermatitis.  To  such  conditions  the  term  pro- 
liferative proctitis  or  proliferating  rectitis  has  been  applied. 

The  discharge  or  drop  is  gonococcus-laden  and  resembles  the  "morn- 
ing drop"  of  chronic  urethritis  in  being  invisible  until  eversion  of  or 
pressure  on  the  anus  brings  it  to  the  front  exactly  as  stripping  the 
urethra  in  either  women  or  men  discovers  the  droplet  of  pus.  In 
females  pressiue  upon  the  anus  from  within  the  vagina  is  efficient. 
The  drop  is  sometimes  from  a  chronic  folliculitis  of  the  anal  verge. 
The  fissure  is  single  or  multiple  and  if  the  former  is  commonly  pos- 
terially  or  under  cover  of  a  condyloma. 

The  termination  follows  a  slow  course  of  doubtful  duration,  excepting 
in  very  mild  cases,  due  to  the  gonococcus,  its  penetrating  power  and 
possibly  the  natural  local  uncleanliness.  The  mild  cases  reach  a  cure 
without  sequels  or  complications  in  about  the  same  period  as  a  m'etlu'itis, 
namely,  one  or  tw^o  months.  The  severe  and  general  cases,  however, 
become  chronic  and  have  sequels.  Chronic  infiltration  and  contractiu-e 
are  not  uncommon.    The  bowel  thus  narrowed  causes  obstruction  of 

1  Rev.  internat.  de  med.  et  de  cliimrgie,  1905,  xvi,  109. 


212     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

function,  then  chronic  inflannnation  of  the  rectum  alone  at  first,  and 
hiter  of  the  intestine  above  it  with  dii^'estive  disorder  and  nudnutri- 
tion. 

Complications. — A  common  terminal  (•om])li('ation  is  a  slimy  jnis 
about  the  anus  and  its  annexa,  with  sodden  eezematous  skin  and  ten- 
dency to  inelasticity  and  stricture  above.  lirunswic-le-Bihan'  recog- 
nizes three  complications:  acute  and  chronic  ])erirectitis  and  stricture. 
Acute  perirectitis  or  ])erii)roctitis  is  ischiorectal  abscess  containing 
rectal  and  intestinal  organisms,  notably  the  liacillus  coli  communis, 
entered  by  lesions  of  the  wall  caused  by  the  gonococcus  which  is  ordi- 
narily not  found  in  the  pus  or  the  walls  of  the  abscess  due  to  vul- 
nerability  of  the  organism,  and  its  difficulties  of  growth,  especially 
in  the  presence  of  such  abundant  other  flora.  Chronic  perirectitis  or 
periproctitis  is  really  an  infiltration  of  the  perirectal  tissues  into 
semicartilaginous  density  with  inelasticity  and  resistance  as  a  bait  or 
strip,  palpable  to  the  finger  and  visible  to  the  eye  b.y  its  bulging  and 
inertia.  Symptoms  of  obstipation,  pressm'e  and  weight  of  foreign 
sulistance  and  constipation,  with  pain  and  tenesmus  due  to  the  mucous 
proctitis  associated  with  the  lesion,  are  common.  Gonococcal  stricture 
of  the  rectmii,  as  in  the  m'ethra,  follows  more  or  less  deep  destruction 
of  the  mucosa  with  ulcers,  scars,  general  thickening,  condylomata  and 
widespread  cicatrization.  This  process  is  within  the  rectal  wall  while 
that  of  chronic  peru'cctitis  involves  the  tissue  outside  it  alone,  or  the 
wall  in  addition.  Both  have  much  the  same  symptoms  as  just  described 
on  page  211. 

Cases  in  literatm-e  of  importance  have  all  been  published  since  the 
development  of  bacteriology,  and  therefore  rest  on  absolute  proof. 
The  fullest  historical  re\iew  of  gonococcal  proctitis  is  giN'en  by  Mermet.^ 
Tuttle^  gives  full  bacteriologic  proof  of  gonococci  in  the  pus  of  these 
three  patients  as  does  also  Grift'on^  in  one  patient.  Hartmann'^  demon- 
strated gonococci  in  an  ulcer  of  the  anus.  These  positi\'e  findings  in 
the  cases  of  Tuttle,  (iriffon  and  Ilartmann  render  them  acceptable. 
Without  full  bacteriologic  })roof  in  smear  and  culture  earlier  case  reports 
which  omit  such  proof  must  be  disregarded  or  discounted.  Bumm*' 
seems  to  have  been  the  first  authority  to  have  established  the  identity 
of  the  gonococcus  in  the  rectum  and  is  so  credited  by  Luys  in  his 
Tc.ri-J)(H)I:  on  (lonorrhcd. 

Diagnosis. — The  clinical  atlmission  or  denial  of  sodomy  in  the  history 
or  of  other  source  of  contamination,  sudden,  severe  onset,  short  period 
of  intense  symptoms  followed  by  subacute  or  chronic  tendency  with 
condylomata  or  antecedent  or  accompanying  genital  gonococcal  infec- 
tion all  tend  to  estal)lish  the  diagnosis.  The  subjecti\'e  symptoms  are 
during  the  acute  period  rectal  pain,  burning,  irritation,  frequent  semi- 

1  Reported  by  Fournier:  Bull,  de  I'Acad.  de  med.,  1907,  Ivii,  501. 

2  Gaz.  des  hop.,  1896,  Ixix,  5.31,  559.        ^  jsjew  York  Med.  .Jour.,  1892,  Iv,  379. 

*  Presse  m6d.,  1897,  p.  71.  ^  Ann.  de  gyiiec.  et  d'obstet.,  1895,  xliii,  77. 

*  Der  Mikro-Organismus  der  gonorrhoischeii  Schleimhaut-Erkraukungen,  Wiesbaden, 
1885,  p.  49,  and  Arch.  f.  Gyniik.,  188-4,  xxiii,  339. 


GONOCOCCAL  ACUTE  PROCTTTrS  213 

diarrheal  evacuation,  mueopunilent  and  purulent  disf;harge  and 
occasionally  bleeding.  In  the  subacute  stage  these  subside  in  degree 
but  the  follicular  proctitis  which  usually  supervenes  may  cause  much 
discomfort  and  the  chronic  warty  growths,  fissure  or  follicular  abscess 
and  pus  about  the  anus  are  complaints  in  the  chronic  stage.  The 
objective  symptoms  are  cardinal  and  include  (1)  the  condylomata 
acuminata  about  and  on  the  anal  muscle  and  in  the  rectum,  (2)  the 
drop  of  stringy  pus  appearing  under  eversion  or  other  pressure  upon 
the  anal  muscle  and  (3)  the  fissure  representing  an  infected  follicle 
with  abscess,  sinus  or  ulcer  and  chronic  drop  of  pus  as  the  final  result. 
The  "funnel  anus"  with  perianal  eczema  marks  the  pervert.  Proctos- 
copy during  the  acute  stage  is  not  as  a  rule  desirable  but  will  reveal 
all  the  signs  of  severe  inflammation,  redness,  edema,  exfoliation,  pus 
containing  the  gonococcus.  Folliculitis  in  the  subacute  and  chronic 
periods  is  characterized  by  inflamed  and  occluded  or  discharging 
follicles,  infiltration,  adherent  strings  and  scabs  of  pus  leaving  a  raw 
surface  and  frequently  containing  the  gonococcus.  The  chronic  period 
shows  one  or  more  follicles  degenerated  into  sinus,  ulcer  or  fissure  and 
condylomata  acuminata  above  the  anus  as  well  as  on  and  external  to  it. 
These  may  extend  several  inches  up  the  bowel  and  be  extremely 
numerous — one  case  of  the  author  showing  several  dozen  of  them. 
The  laboratory  findings  are  very  important.  The  fact  that  the  Micro- 
coccus catarrhalis  is  gram-negative  in  its  early  periods  and  gram- 
positive  in  its  later  developments  and  closely  resembles  the  gonococcus, 
makes  careful  bacteriology  absolutely  essential,  combined  with  the 
use  of  the  proctoscope  for  the  distinction  of  objective  symptoms. 
Often  an  active  folliculitis  will  be  found  within  the  rectiun  or  at  the 
anus,  whose  pus  when  carefully  secured  will  be  free  from  other  organ- 
isms than  the  gonococcus  and  settle  the  question.  Smear,  cultiu-e  and 
complement  fixation  test  make  up  the  chain  of  e^^dence.  Treatment 
is  of  no  direct  aid  in  the  diagnosis  with  the  exception  that  removal  of 
the  adherent  scab  and  strings  of  pus  furnish  good  specimens  for  the 
laboratory  as  does  likewise  evacuation  of  foflicles.  Antigonococcal 
antiseptics  are  also  of  suggestive  value. 

On  this  general  subject  Lynch^  says:  "In  gonorrheal  proctitis  the 
anus  has  a  rather  tji^ical  appearance.  Where  the  disease  is  acquired 
innocently,  especially  from  massage  of  the  prostate,  the  sphincter  is 
spasmodicaUy  contracted  and  the  mucocutaneous  membrane  is  red; 
but  after  the  disease  has  existed  for  some  days,  the  skin  becomes 
macerated,  and  is  covered  by  a  mucopm'ulent  discharge.  In  the  case 
of  sexual  perverts,  the  skin  around  the  anus  is  thrown  into  edematous 
folds.  It  has  a  cyanotic  or  bluish-red  appearance,  and  is  covered  by 
mucus  mixed  with  pus.  In  some  cases  the  mucous  membrane  is  pro- 
lapsed, and  it  is  with  difficulty  that  the  speculum  can  be  passed  very 
high.  Here  and  there  we  see  flakes  of  mucus  and  pus  resembling  those 
of  severe  peritonitis.    The  flakes  are  adherent  to  the  mucous  membrane, 

1  Diseases  of  the  Rectum  and  Colon,  1914,  p.  278. 


214     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

and  when  remoNod  leave  a  raw,  bleeding  surface.  The  mucous  mem- 
brane in  all  cases  bleeds  very  easily." 

Differential  Diagnosis  is  concerned  chicHy  with  catarrhal  i)roctitis  and 
syjihilis  and  chancroids  of  the  anus. 

Catarrhal  differs  from  gonococcal  proctitis  in  the  absence  of  any  history 
of  anteeeilent  infection  or  of  perversion;  in  the  much  less  intense 
subjective  symptoms  and  in  objective  symptoms  of  haxing  mucus  and 
mucoi)us  rather  than  ])us  as  the  dischariiv;  in  the  freedom  from  the 
strintjcs  and  scabs  of  i)us  leaving  bleeding  surfaces  when  removed  and 
like  the  free  pus  containing  gonococci;  in  the  failure  of  laboratory 
findings  to  detect  the  specific  organism  or  the  eom])lement  fixation 
test  and  in  the  promi)t  res])onse  to  simple  treatment  of  the  catarrh. 

Si/jihilific  differs  frovi  gonococcal  proctitis  in  the  absence  of  an\' 
gonococcal  findings  whatsoe\'er  in  the  history  and  in  the  presence  of 
abundant  signs  of  syphilis  elsewhere  in  the  body  and  in  the  blood  as  a 
Wassermann  test.  It  may  appear  about  the  anus  as  moist  papules, 
condylomata  lata  and  gumma  each  having  its  own  features.  The  moist 
l)apules  resemble  the  mucus  patches  of  the  mouth  in  being  slightly 
raised  above  the  surface,  siu'rounded  with  indolent  inflammation  and 
infiltration  and  in  having  a  moist  "varnished"  siu-f  ace,  serous  discharge 
and  the  Trei)onema  pallidimi  abundant.  This  process  does  not  extend 
materially  into  the  rectmii  ])roper,  and  bears  little  resemblance  to 
gonococcal  warts.  The  condylomata  lata  might  be  regarded  as  exag- 
gerations of  the  moist  papules  in  being  sessile,  slightly  raised  above  the 
surface,  sun-oimded  by  inflammation  and  infiltration,  fissured,  and 
co\'ered  with  moist,  thick  discharge.  The  organism  of  syphilis  is  in 
the  discharge  and  the  sm-face  and  substance  of  the  outgrowth.  These 
likewise  do  not  extend  above  the  anus  in  themselves  but  may  provoke  a 
secondary  infection  of  the  rectmn  of  catarrhal  or  purulent  type.  The 
gumma  is  essentially  a  neoplasm  although  of  temporary  character 
under  treatment,  deeply  infiltrates  the  tissue  and  may  be  a  prominent 
and  extensive  mass,  occurring  singly  or  severally.  It  is  of  peculiar 
purple  lividity,  and  has  a  decided  tendency  to  necrosis  at  the  center 
whose  secondary  infection  may  extend  up  the  bowel.  The  condylomata 
acmninata,  on  the  other  hand,  are  not  sessile  but  pedunculated,  finely 
and  coarsely  fibrillated  and  lobulated  exactly  like  a  cock's  comb,  dry 
rather  than  moist  unless  between  closely  apposed  surfaces,  bleed  easily, 
are  very  friable  and  in  smaller  examples  will  break  oft'  in  the  fingers. 
Their  discharge  contains  only  the  gonococcus.  Exceptionally  these 
condylomata  are  found  without  the  presence  of  gonococcal  infection 
but  with  the  existence  of  uncleanly  habits  and  deep  folds  of  the  skin 
especially  around  the  anus  and  genitals  where  eczema  intertrigo  is  very 
common.  They  then  represent  a  hypertrophic  change  in  the  skin  due 
to  the  eczema  and  the  infection  of  the  organisms  present  normally  in 
the  skin  but  augmented  by  the  uncleanliness  of  the  victim. 

The  history'  therefore  points  only  toward  syphilis  and  away  from 
gonococcal  infection  in  the  long  incubation,  development  and  course 
of  the  chancre,  appearance  and  progress  of  the  secondary  symptoms 


r;r,\ocoCCAL  ACUTE  PROCTITIS  215 

of  which  these  cutaneous  anal  signs  are  only  a  part  or  of  the  tertian* 
symptoms  with  the  incidenc-e  and  ulceration  of  the  gnunma.  The 
subjective  s\Tnptoms  haAe  just  been  sufficiently  stated  and  should  be 
corroborated  by  objective  examination,  both  of  the  general  symptoms 
and  of  the  local  outgrowths  of  the  disease,  without  omission  of  search 
for  the  Treponema  pallidum  and  the  Wassermann  or  Xoguchi  com- 
plement fixation  tests  for  syphilis  as  the  chief  elements  in  the  labora- 
tory e^'idence,  which  after  all  is  final.  The  treatment,  systemic  and 
local,  against  s^"philis  is  so  prompt  in  its  results  that  it  has  been  called 
the  "touchstone"  of  diagnosis  in  these  cases,  and  is  of  great  service 
in  cases  giving  negative  or  contradictory  laboratory*  reports. 

Chancroidal  differs  from  gonococcal  proctiii^s  in  being  primarily  an 
external  ulcerative  process  and  secondarily  a  pmiilent  infection  of  the 
bowel  which  may  not  occur  at  all.  The  history*  is  that  of  pen'erted 
sexual  congress  or  of  the  presence  of  chancroid  about  the  genitals  and 
its  appearance  at  the  anus  by  autoinoculation.  The  subjective  s^^np- 
toms  embrace  all  the  irritation,  pain,  spasm,  bleeding  and  discharge  of 
fissure  in  ano  and  the  objective  findings  reveal  the  tApical  chancroid 
with  "mouse-eaten  or  gnawed"'  base  and  overhanging  ragged  edges 
and  purulent  slightly  hemorrhagic  discharge.  Proctoscopy,  if  possible 
to  the  patient,  reveals  a  purulent  proctitis  without  the  development 
of  condylomata  acuminata  within  the  boweh  without  adherent  scabs 
and  strings  and  without  any  of  the  other  signs  of  gonococcal  proctitis, 
including  the  gonococcus  itseh.  The  laboratory"  investigation  proves 
the  presence  of  the  bacillus  of  Unna  and  Ducrey  and  freedom  from 
the  gonococcus  in  the  ulcer  and  its  pus  and  the  pus  from  the  bowel. 
The  gonococcal  complement  fixation  test  is  negative.  Treatment 
against  chancroid  and  other  ulcer  is  available.  The  bowel  requires 
no  attention  unless  secondare-  infection  of  it  shall  have  occurred. 
Curetting  and  section  of  the  sore  will  reveal  the  I'nna-Ducrey  baciQus 
in  the  substance  of  the  growth  and  in  the  discharge  and  sloughs  from 
its  surface. 

Treatment. — In  the  discussion  of  gonococcal  conditions,  significance 
shows  that  proctitis  is  one  of  the  more  important  compHcations 
through  the  lesions  produced  by  direct  infection,  incidentally  through 
carelessness  or  intentionally  by  perversion.  The  latter  is  a  factor  in 
these  cases  of  grave  social  moment.  The  prophylaxis  of  the  disease 
pro^"ides  against  transmission  of  pus  from  the  genitals  to  the  rectum 
by  instructions  concerning -clean  hands  and  disposal  of  dressings  as 
shown  in  detail  in  the  printed  shps  of  instruction  given  in  the  early 
paragraphs  on  treatment.  Abortion  reaches  its  aim  by  early  and  judi- 
cious attack  on  the  first  symptom  of  bacteriologically  proved  infection. 

The  particulars  of  management  are  enumerated  in  Chapter  IX  on 
General  Principles  of  Treatment  on  page  4S3. 

Curaiive  Treatment. — ^Removal  of  exudate  is  the  first  step  and  irri- 
gation is  the  first  method  during  the  period  of  discharge  followed  by 
expectant  applications  in  the  chronic  period. 

The  stool  should  be  soft  and  pultaceouSj  as  in  fissura  in  ano,  as 


21G      COMPLICATIONS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

produced  by  the  folKnviiig  foriiuila  iii  one  or  two  movements  ca  day, 
black  and  foul-smelluig,  concerning  Avbich  the  patient  should  be  warned. 

]^ — Flowers  of  sulphur, 

Sulphate  of  magucshmi,  of  each 1  ounce  (30.0  grammes) 

Mix,  make  a  powder  and  mark: 

One  to  fout  tcaspoonfuls,  as  needed,  for  soft  movements. 

The  physical  measures  are,  in  hy(ir()thera])y  rectal  irrigations  as 
soon  as  the  intense  symptoms  disapjK^ir,  at  lirst  sohent  and  cleansing 
to  remove  mucus  and  pus,  then  antiseptic  and  stimulating.  Sitting 
baths,  hot  to  produce  redness  of  the  skin,  decongest  the  deep  pelvic 
circulation  and  soothe  the  diarrhea  and  tenesmus.  In  electrotherapy 
fulguration  removes  the  warts  by  the  same  procedure  as  tletailed  in 
this  technic  for  condyloma  acuminatum,  substituting  the  proctoscope 
for  the  urethroscope.  The  medicinal  measures  are  standard  attention 
to  the  urethritis.  During  the  acme,  extreme  irritation  forbids  active 
treatment,  but  the  sphincter  may  be  stretched  under  nitrous  oxide  gas 
anesthesia,  as  in  fissure,  and  Irish  moss  lubricant,  containing  a  small 
amount  of  novocain  or  alypin  may  be  inserted  as  sedative.  JNIorphin 
and  opium  suppositories  check  the  pam  and  the  tenesmus,  aided  by 
soft  stools.  ]\Ioist  antiseptic  dressings  receive  the  discharge  and  keep 
apposed  surfaces  from  chafing.  Serumtherapy  offers  no  advantage. 
Local  administration  is  involved  M'ith  the  declinhig  period  exactly  as 
in  urethritis.  Through  the  double  current  rectal  tube  or  two  catheters 
inserted,  side  by  side,  warm  normal  salt  solution  or  weak  boric  acid 
water  are  rmi  in  until  the  return  is  clear,  followed  by  solutions  of  potas- 
sium permanganate,  1  in  10,000  to  1  in  4000;  silver  nitrate,  1  in  20,000 
to  1  in  5000;  bichloride  of  mercury,  1  in  10,000  to  1  in  5000.  After 
these,  argyrol,  3  to  10  per  cent.;  protargol,  1  to  2  per  cent.;  collargol, 
10  per  cent.;  silver  nitrate,  0.5  to  1  per  cent.,  may  be  instillated  and 
retained.  In  the  still  later  periods  the  proctoscope  or  the  small  Sims 
speculum  in  either  the  knee-chest  or  the  Sims  posture  is  employed  for 
making  light  applications  of  nitrate  of  silver  in  more  stimulating  and 
caustic  strengths,  1  to  25  per  cent.,  and  its  allies  to  ulcerations  and 
indolent  granulations  anfl  for  fulgurating  warts  from  within  the  canal 
or  surgically  removing  them.  The  anal  eczema  indicates  cleanliness 
by  washing  with  castile  soap  and  water  and  thoroughly  dr^'ing  w'ith  a 
towel,  aided  with  dusting  powders,  such  as  equal  parts  of  boric  acid, 
th.Miiol  iodide  and  bismuth  subnitrate.  Painting  of  the  eczema  with 
10  per  cent,  nitrate  of  silver  is  a  strong  healing  agent  against  the  infec- 
tion and  the  relaxation.  Dressing  to  receive  the  irritating  discharge 
and  to  separate  the  surfaces  is  essential  and  should  be  at  first  moist 
antiseptic  gauze  or  cotton  followed  by  the  same  liberally  dusted  with 
stearate  of  zinc  and  boric  acid  powder  or  by  a  soothing  ointment,  such 
as  equal  parts  of  10  per  cent,  ichthyol  and  10  per  cent,  boric  acid. 

The  surgical  measures  begin  with  overstretching  of  the  sphincter 
ani  muscle  to  correct  tenesmus  and  to  permit  applications  more  readily. 
Through  a  small  Sims  speculum  or  the  10  cm.  proctoscope  the  mucosa 


GONOCOCCAL  PERfTONITTS  217 

is  directly  treated  and  warts  may  be  fulgurated  in  the  exact  manner 
prescribed  for  urethral  growths  or  surgically  ablated.  In  the  latter 
technic  they  are  drawn  forward  and  clipped  through  their  bases  after 
ligation,  so  that  the  wart  and  its  pedicle  are  ablated.  The  raw  stump 
may  be  touched  with  10  per  cent,  silver  nitrate.  Folliculites  are  incised, 
cauterized,  drained  and  dressed  in  miniature  like  an  ischiorectal 
abscess.  Fissures  are  incised  througli  the  granulating  zone  to  sound 
muscle  tissue  and  dressed,  after  the  preliminary  stretching  of  the  muscle. 
Sources  of  discharge  are  so  far  as  possible  located  and  approjjriate  appli- 
cations made  to  areas  of  indolent  granulation  and  to  pockets  accumu- 
lating pus.  A  small  cotton  tampon  soaked  in  suitable  medications 
may  be  inserted  through  the  speculum  until  the  next  defecation. 

Aftertreatment. — The  chief  aim  is  to  restore  the  mucosa  to  normal 
after  the  infection  is  removed,  which  may  require  weeks  and  months, 
exactly  as  in  the  urethra.  Avoidance  of  constipating  or  diarrheal  diet 
and  drink  is  required  and  full  hygiene  of  the  urethritis  must  never  be 
omitted  in  order  to  avoid  reinfection. 

Cure,  pathologically,  means  no  panproctitis,  with  its  cicatrices  and 
chronic  catarrhal  discharge,  and  s^Tiiptomatically  there  must  be  no 
relapse  of  the  catarrh  or  the  infection  from  any  uncured  fissure, 
follicle  or  wart  and  no  excoriating  mucous  or  purulent  discharge;  and 
bacteriologically  the  gonococcus  must  be  permanently  absent  after 
repeated  smear  and  culture  test  and  the  flora  of  the  bowel  restored 
as  nearly  as  possible  to  the  normal.  Cure  of  the  urethritis  to  the 
standard  previously  described  is  a  foundation  of  proper  result  in  the 
rectal  disease.    Cessation  of  unnatural  practices  is  absolutely  indicated. 

GONOCOCCAL  PERITONITIS. 

Significance. — Although  the  peritoneum  is  not  actually  an  organ  of 
the  digestive  tract,  it  is  so  intimately  associated  with  it  that  sjTiiptoms 
of  peritonitis  are  locally  chiefly  digestive.  For  this  reason  it  was 
regarded  logical  to  include  the  complication  of  gonococcal  peritonitis 
under  the  heading  of  complications  of  the  digestive  system. 

Its  significance  recalls  the  fatal  results  and  the  late  sequels  and 
invalidism  which  mark  peritonitis  as  one  of  the  most  important  of  all 
the  sequels  of  gonococcal  infection.  In  the  male  it  is  fortunately  rare, 
because  there  is  no  direct  connection  between  the  urogenital  system 
and  the  serosa,  but  in  the  female  it  is  lamentably  more  common  because 
the  mucosa  of  the  tubes  is  directly  continuous  with  the  serosa.  With 
modern  and  improved  treatment  of  gonococcal  disease  it  is  much  less 
common  in  either  sex  than  it  was  in  previous  generations. 

Occurrence. — In  actual  frequency  gonococcal  peritonitis  is  in  the  male 
a  rare  disease,  never  primary  but  always  secondary  to  or  associated 
with  disease  of  the  seminal  vesicles,  prostate  and  perivesical  region, 
with  burrowing  of  the  pus  in  the  deep  celhdar  planes  until  the  peri- 
toneum is  reached.  It  is  much  more  common  in  the  female,  owing  to 
the  fact  that  the  Fallopian  tubes  open  directly  from  the  peritoneal 


218     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

cavity.  In  chiUlren  it  is  most  common  and  nsnally  of  fulminatine; 
type.  The  disease  in  women  and  children  is  discnssed  in  (diai)ter 
XI  on  jiaues  ()12  and  lil"). 

Varieties. — Acute,  subacute  and  chronic,  locaUzed  and  partially 
or  generally  diffuse  are  the  forms  seen,  of  which  the  most  usual  are 
(1)  in  the  niale,  acute  localized;  (2)  in  the  female,  acute  and  ])artially 
diffuse  within  the  ])elvic  cavity  and  (o)  chronic  relapsinj^with  adhesions, 
es])ecially  seen  in  women. 

Etiology. ^ — The  gonococcus,  with  its  pyogenic  allies,  is  the  exciting 
factor,  A\hik"  the  associated  disease  is  the  predisposuig  condition, 
notably  coni])lications  in  spermatocystitis,  jn-ostatitis,  both  with 
abscess  and  iini>hement  of  the  surrounding  tissues.  Fuuiculitis  of 
severe  type  is  a  particularly  common  cause  especially  where  the  vas 
deferens  reaches  the  wall  of  the  bladder  from  the  inguinal  canal  and, 
in  direct  contact  with  the  i)eritonemn,  passes  along  it  to  its  am])ulla  at 
the  l^ase.  The  ])eritoneal  annexa  of  all  these  organs  in  the  rectovesical 
cul-de-sac  are  the  point  of  onset  of  the  peritonitis. 

Pathology, — Primary  cases  never  occur,  because  the  gonococcus 
cannot  reach  the  ])eritoneum  except  through  complications  in  and  break 
down  of  neighboring  organs  in  more  or  less  direct  relation  with  this 
membrane,  t'econdary  cases  are,  therefore,  the  one  rule.  The  essence 
of  the  process  is  extension  to  the  serous  sac  of  the  abdomen  of  the 
gonococcal  infection,  with  or  without  its  common  pyogenic  allies  from 
a  previous  jjoint  of  infection — invariably  a  complication  in  the  peri- 
lU'ethral  structures  in  the  male.  The  tissues  invohed  are  the  organs 
in  such  complication  and  the  peritoneum  locally  in  the  strict  sense  or 
diffusely  within  the  cavity  of  the  true  pelvis  or  throughout  the  peri- 
toneal cavity  as  a  whole.  The  temporary  lesions  in  cases  of  recovery 
are  those  essential  to  gonococcal  invasion — congestion,  inflammation, 
exfoliation,  infiltration  and  purulence,  which  is  relatively  scanty  in 
fluid  amount  but  copious  in  fibrous  products  with  secondary  delicate 
adhesions.  The  permanent  lesions  are  extensions  of  these  processes 
into  dense  adhesions,  which  displace  the  intestines  and  the  organs, 
especially  in  the  female,  to  severe  compromise  of  function,  digestive 
and  sexual.  The  associated  lesions  are  those  of  the  causati\'e  or  pre- 
cedent involvement,  while  the  bacteriology  is,  as  stated,  the  gono- 
coccus with  or  without  its  common  pyogenic  aids.  Mixed  infections 
are  commonly  the  most  severe. 

S5miptoms. — As  in  any  other  peritonitis  the  gonococcal  form  has  much 
tlie  same  local  and  general  subjectiA'e  and  objective  syndrome  dm'ing 
the  periods  of  invasion,  establishment  and  termination.  The  initial 
s.Miiptom  of  the  invasion  is  usually  local,  as  a  severe  sudden  colic, 
which  in  children  is  intense  and  prostrating.  This  is  followed  by  chill 
and  chilliness,  high  fe\er  and  the  other  common  signs  of  infectious 
invasion.  In  the  establishment  the  subjective  systemic  symptoms 
are  continuation  of  the  rigors,  with  high  variable  temperature,  nausea, 
vomiting,  first  of  bilious  and  later  fecal  type,  constipation  from  par- 
alysis of  the  bowel  and  exceptionally  diarrhea.    The  objective  systemic 


GONOCOCCAL  PERJTONTTIS  210 

signs  at  the  corresponding  time  are  the  high  variable  fever,  parti<:u- 
larly  in  children,  a  rapid,  tense  pulse,  intense  anxious  mind,  due  usually 
to  the  pain  and  the  character  of  the  toxemia.  The  subjective  local 
signs  are  extension  of  the  colic  into  severe  pain  (;onfined  to  the  pelvis, 
the  lower  part  or  the  whole  of  the  abdomen,  while  tlic  objective  }>oints, 
less  in  localized  than  in  generalized  disease,  are  tenderness  and  muscular 
tension  over  the  seat  of  the  pain,  gradual  inflation  until  the  whole 
abdomen  is  "ballooned."  Motion  and  touch  augment  the  suffering 
exemplified  by  the  anxious,  sallow,  haggard  expression.  Jicctal 
examination  commonly  reveals  the  causative  focus  in  the  seminal 
vesicles,  prostate  and  annexa,  and  sometimes  localized  tenderness  in 
the  cul-de-sac  to  the  examiner  with  a  long  finger. 

The  termination  in  mild  local  cases  is  full  recovery,  with  or  without 
adhesions,  which  may  lead  to  secondary  rectal  and  intestinal  difficulty. 
More  extensive  cases  may  also  permit  recovery,  while  the  intense 
generalized  involvements  commonly  terminate  fatally. 

Diagnosis. — Recognition  of  two  facts — the  peritonitic  process  and 
the  gonococcus  as  the  exciting  agent — is  the  basis  of  the  diagnosis. 
The  history  is  completed  by  the  antecedent  intense  gonococcal  infec- 
tion with  numerous  and  severe  complications,  especially  those  of  the 
prostate  and  seminal  vesicles,  with  absorption  systemically  and  with 
extension  into  the  annexa  of  these  organs  locally  in  the  male  and  in 
the  female  duplicate  processes  in  the  womb,  tubes  and  -ovaries.  The 
subjective  sjmiptoms  are  those  of  intense  pain  localized  in  the  region 
of  the  affected  organs  with  a  tendency  to  advance  and  extend.  Diffi- 
culties with  bladder  and  rectum  may  be  present.  The  objective  signs 
are  those  first  of  the  initial  gonococcal  condition  and  its  complications, 
and. second  those  of  the  localized  peritonitis.  In  the  female  through 
the  rectum  the  cul-de-sac  of  Douglas  may  be  perceived  to  have  lost 
its  usual  freedom  and  smoothness  and  to  have  been  replaced  by  infil- 
tration and  adhesions,  in  association  in  the  male  with  the  diseased 
prostate,  vesicles  and  vas  deferens  and  in  contact  in  the  female  with 
the  boggy  uterus  and  invaded  tubes  and  ovaries  and  sometimes  the 
bladder  in  either  sex.  In  the  male  the  peritonitis  may  be  suggested 
by  extensive  tenderness  along  the  course  of  the  vas  deferens  within 
and  just  above  the  inguinal  canal.  On  the  whole  the  general  character 
of  the  fever  is  less  variable  and  intense  in  pure  gonococcal  peritonitis 
than  in  the  true  pyogenic  form  excepting  children  and  the  sudden  onset 
of  localized  abdominal  pain  during  the  activity  of  any  of  the  essentially 
severe  complications  of  gonococcal  m'ethritis  followed  by  the  other 
classical  symptoms  of  peritonitis  will  practically  settle  the  question. 
The  laboratory  findings  ofter  suggestive  factors  in  the  decision  such  as 
the  presence  of  gonococcal  infection  in  the  urogenital  organs,  especially 
of  its  complications  in  those  organs  which  are  particularly  in  relation 
with,  for  example,  in  the  male  the  bladder,  prostate,  seminal  vesicles 
and  vasa  deferentia  and  in  the  female,  the  tubes  and  ovaries.  It  is 
obvious  that  the  final  decision  as  to  the  identity  of  gonococcal  involve- 
ment in  the  peritonemn  cannot  be  reached  without  recovery  of  exudate 


220     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

from  the  i>eritoneal  cavity  which  m  tlie  male  is  extremely  (lifTiciilt, 
hut  in  the  female  in  oi)erative  cases  is  much  easier  when  the  organs 
within  the  pehis  are  freed  of  adhesions  and  exposed  for  the  securing 
of  specimens.  Only  in  this  sense  is  treatment  of  value  in  the  diagnosis. 
The  compleinent  fixation  test  is  very  apt  to  be  positive. 

Differential  Diagnosis. — Peritonitis  arising  during  a  com])li(atcd  ure- 
thritis may  hv  due  to  the  i)yogenic  organisms  conunonly  found  with 
the  gonococcus  in  these  cases  but  its  recognition  would  depend  on  its 
more  active  and  progressing  character  and  the  distinction  of  the  pyo- 
genic germs  to  the  exclusion  of  the  gonococcus  in  the  ])us.  This  would 
well-nigh  be  impossible  except  as  an  element  of  operative  intervention 
or  autopsy. 

Treatment. — The  fatal  issues  and  invalidating  sequels  in  their 
significance  identify  peritonitis  as  a  grave  complication  and  ])r()])hy- 
laxis  oH'ers  no  direct  means,  but  efficient  indirect  means  by  earl>-  and 
proper  attention  to  the  comi)lications  in  the  female  involving  tube  and 
ovary  and  by  free  e^•acuation  and  drainage  of  pus  accmnulated  in  the 
male  among  the  cellular  planes  of  the  pelvis  seen  in  abscess  of  the 
seminal  vesicles,  prostate  and  pancystitis.  There  is  no  aborti\^e  treat- 
ment because  when  the  infection  has  once  reached  the  i)eritoneum 
it  cannot  be  checked  but  it  may  be  localized  and  prevented  from 
becoming  diftuse.  Proper  treatment  may  therefore  be  abortive  of 
generalized  disease. 

The  student  must  learn  the  essentials  of  management  in  Chapter  IX, 
on  General  Princii)les  of  Treatment,  on  page  4S3. 

Curative  Treatment. — ^This  is  active  and  prompt,  but  is  often  of  little 
avail  and  yet  may  save  seemingly  hopeless  cases  and  limit  severe 
infections  to  one  part  of  the  abdomen. 

'i'he  physical  measures  offer  the  ice-cap  or  the  ice-water  coil  to  the 
abdomen  or  hot  poultices  in  the  hydrotherapy  according  to  the  prefer- 
ence of  the  patient  and  the  benefits  of  each  form  of  treatment.  The 
]\Iurphy  enteroclysis  belongs  under  this  heading. 

The  heliotherapy  requires  a  500  c.p.  therapeutic  lamp  slowly  wav- 
ing o\er  the  affected  part  for  at  least  thirty  minutes  four  times  a 
day  and  persisted  in  until  subsidence  of  symptoms,  which  is  induced 
by  the  intense  hyperemia,  increase  in  the  resistance  and  activity 
of  phagocytosis  followed  by  relief  of  the  pain.  The  electrotherapy 
applies  the  hot  electric  coil,  if  heat  is  beneficial,  or  the  .r-ray  in  the 
chronic  stages  to  promote  absorption  of  extensive  exudate.  The  cm*- 
rent  is  3  milliamperes,  backing  up  a  4  inch  spark  gap  at  the  negative 
terminal  of  the  a;-ray  tube  placed  at  a  distance  of  10  inches  from  the 
part,  imder  the  protection  of  3  mm.  of  aluminum  upon  either  4  layers 
of  chamois  or  1  layer  of  sole  leather.  The  duration  is  fifteen  minutes 
but  varies  with  the  result  and  the  frequency  is  alternate  days  for  ten 
treatments  and  then  two  times  a  week.  Unfavorable  reaction  is 
unknown  in  competent  hands. 

All  medicinal  measures  suggest  small  doses  of  calomel  or  sul])hate 
of  magnesium  to  avoid  stasis  of  the  bowel  followed  by  paralysis  and 


GONOCOCCAL  PERITONITIS  221 

distention  but  are  given  cautiously  if  there  is  diarrhea.  Small  doses  of 
opium  derivatives  to  ease  spasm  and  pain  arc  rcfjuircd ;  the  use  of  large 
doses  of  opiates  to  control  all  spasm  and  pain  is  no  longer  advised  on 
account  of  its  disadvantages  of  constipation,  prevention  of  absorption 
of  exudate,  masking  of  new  symptoms  and  sometimes  depression.  On 
the  other  hand,  a  single  large  dose  will  relieve  the  shock  of  intense  jjain, 
especially  in  a  perforating  case.  Splanchnic  vascular  paralysis  with 
secondary  cardiac  paralysis  is  seen  in  diffuse  peritonitis  and  Kolt/J 
gives  pituitrin  for  the  low  blood-pressure,  ileus  and  ischuria  of  such 
paralysis. 

The  surgical  measures  never  neglect  the  focus  of  onset,  such  as 
spermatocystitis,  prostatitis  and  pancystitis,  any  or  all  with  abscess 
and  involvement  of  the  surrounding  tissues.  The  nonoperative  means 
are  Fowler's  position  and  Murphy  enteroclysis  as  noted  on  page 
415.  The  operative  technic  rests  on  the  severity  of  the  symptoms 
and  the  type  of  the  infection  present.  The  latter  is  often  impossible 
to  determine.  Operation  may  be  immediate  or  postponed  with  both 
dangers  and  benefits.  Immediate  interference  may  excite  an  inflam- 
mation which  would  otherwise  decline  and  postponed  operation  has  the 
dangers  of  advance  in  old  and  of  appearance  of  new  lesions  with  adhe- 
sions and  invalidism,  relieved  only  by  later  operation.  Its  benefits 
make  the  operation  one  of  election,  greater  safety  and  often  better 
immediate  and  remote  functional  results.  Minor  operation  is  blood- 
letting in  sthenic  patients,  with  localized  peritonitis  a  small  quantity  of 
blood  being  withdrawn.  Even  multiple  leeches  helpfully  reduce  pressure 
and  remove  toxins. 

The  major  operation  is  laparotomy  by  incision,  evacuation  and 
drainage  of  the  abdominal  cavity,  without  or  with  flushing,  irrigation 
or  mopping.  The  selection  of  case  concerns  local  and  diffuse  peri- 
tonitis. The  local  cases  have  focal  inflammation,  symptoms  and  exu- 
date, with  comparatively  little  systemic  disturbance,  much  as  is  seen  in 
some  forms  of  appendicitis  and  pus  tubes.  Relief  comes  with  incision, 
evacuation,  cleansing  and  drainage  analogous  to  an  abscess.  The 
generalized  peritonites  have  diftuse  abdominal  pain  and  most  intense 
systemic  symptoms  in  contrast,  especially  in  cases  of  general  peri- 
toneal septicemia  proceeding  from  postoperative  infection,  puerperal 
fever,  strangulated  hernia,  intestinal  obstruction  and  the  like.  Relief 
of  these  cases  is  not  unlike  removal  of  accumulated  poison  from  the 
stomach.  Operative  energy  against  the  cause  of  the  peritonitis  is 
imperative. 

The  instruments  and  supplies  are  scalpels,  scissors,  forceps,  hemo- 
stats,  ligatures,  retractors,  sponge-holders,  gauze  sponges,  intestinal 
pads,  return  flow  irrigation  tube,  assorted  needles,  including  intestinal 
needles,  needle-holders,  sutures,  drains  and  abundant  hot,  normal 
salt  solution.  The  preparation  of  the  patient  usually  omits  catharsis 
and  of  the  field  is  the  standard  iodin  application  for  the  skin  and  the 

1  Miinchen.  med.  Wchnschr.,  September  17,  1912. 


'2J2     COMPLICATIONS  AND  SEQUELS  OF  ACUTE   URETHRITIS 

anesthesia  is  general  and  well  witliin  any  danger  of  depression.  Etiier 
for  its  stinnilation  is  preferred.  The  posture  is  supine  or  Trendelen- 
burg's, according  to  accessibility  of  the  essential  deep  field.  The  land- 
mark is  the  middle  line  of  the  body  from  the  sym])hysis  pubis  to  the 
xiplu>iil  cartilage.  The  incision  in  localized  peritonitis  is  over  the  jioint 
of  most  prominent  symptoms,  most  commonly  the  pelvis  in  gonococcal 
cases  in  lx)th  sexes,  and  in  generalized  peritonitis  it  is  extended  upward 
to  give  free  entrance  to  the  infected  cavity.  The  midline  is  preferred, 
marking  the  superficial  field  between  the  recti  muscles  or  through  the 
sheath  of  one  with  separation  of  the  fibers  or  pushing  of  the  muscle 
aside.  The  deep  field  embraces  all  pockets  in  diti'use  peritonitis,  com- 
monly reaching  the  pelvis  last,  because  the  most  dependent,  and 
embraces  in  local  peritonitis  the  obvious  center  of  accumulated  pus. 
Distended  intestines  are  aspirated  free  of  gas  and  Huid  and  the  needle 
holes  are  stitched  tight. 

The  steps  of  operation  are  individualized  according  to  serous  exudate, 
purulent  exudate  and  fibrinous  exudate,  with  the  modern  tendency  to 
do  as  little  mani])ulation  as  possible,  and  far  less  than  formerly. 

In  localized  peritonitis,  usually  purulent,  the  pus  is  evacuated 
through  the  wound  walled  off  with  gauze  from  the  general  peritoneal 
cavity  if  not  so  by  adhesions.  The  walls  of  the  abscess  are  gently 
mopped  clean  and  free  drainage,  Avith  cigarette  gauze  drains  or  rubber 
tubing  fenestrated  but  without  sharp  edges  or  corners,  is  established. 
A  copious  dressing  covers  the  wound  often  narrowed  to  near  the  drains 
and  after  two  or  three  days,  cleansing  and  drainage  are  encouraged  by 
gentle  irrigation. 

In  generalized  peritonitis,  if  serous,  the  abdomen  is  opened  through 
the  middle  line  and  as  much  of  the  exudate  made  to  escape  as  possible, 
so  as  to  turn  the  balance  of  the  infection  in  the  patient's  favor  by" 
eliminating  much  infectious  material.  The  wound  is  then  sewed  up 
without  drainage  and  commonly  recovery  occurs.  Much  credit  is  due 
to  Iv.  T.  Morris^  for  the  development  of  this  simple,  safe  plan.  If  the 
exudate  is  seropurulent  or  purulent  a  larger  incision  and  irrigation  with 
the  return-flow,  soft-rubber  or  metal  tubes  are  required  in  many  cases. 
The  dependent  pockets  of  the  cavity  are  gently  washed  first  until  the 
return  is  clear,  so  as  not  to  float  mfectious  material  gravitated  into  them 
about  the  cavity.  After  this  the  coils  of  the  intestine  may  be  cleansed 
by  washing  and  gentle  mopping,  always  with  the  protection  of  hot 
towels  against  chilling.  As  little  fluid  as  possible  is  left  in  the  abdo- 
men and  cigarette  drains  are  carried  to  all  depths.  Counterdrainage 
through  the  loin  is  less  commonl}'  emplo}-ed  than  formerly,  but  may  be 
reserved  for  extreme  cases. 

The  stasis  of  the  bowel  in  any  form  of  i)eritonitis,  through  disten- 
tion, is  relieved  by  aspiration  of  gas  and  fluid  contents  and  often  by 
injecting  into  it  concentrated  solutions  of  sulphate  of  magnesium. 

In  the  fibrinous  or  plastic  peritonitis,  with  the  intestines  patched  with 

'  Lec-turcs  on  Appendicitis  and  Notes  on  Other  Subjects,  1S99,  pp.  64,  65,  66  and 
84;  Dawn  of  the  Fourth  Era  in  Surgery  and  Other  Short  Articles  Previously  Pub- 
lished, 1910,  pp.  39  and  117. 


GONOCOCCAL  PERITONiriH  223 

fibrin  and  adherent  in  many  places,  it  is  usual  to  remove  the  loose  exu- 
date from  the  cavities  with  irrigation  and  mopping  in  tlie  sarn(;  rnaiiner 
as  described,  leaving  little  or  no  fhiid  behind,  an/l  to  mop  tlic  less  adher- 
ent patches  away.  Adhesions  are  gently  broken  down  and  the  raw 
surfaces  sometimes  turned  in  with  Lembert  stitches  to  prevent  return 
if  the  patient's  condition  permits,  but  if  Nature's  processes  have  been 
efficient  they  may  be  left  alone.  If  a  perforation  is  walled  ofl"  it  must 
be  exposed  and  closed  with  banked  Lembert  stitches.  Cigarette  drains 
may  be  used  into  any  pus  cavities  in  these  cases. 

The  cause  or  source  of  peritonitis  should  in  most  cases  be  sought 
and  remedied  if  other  conditions  of  the  patient  and  operation  permit. 
When  gonococcal  infection  is  suspected  as  the  sole  cause  the  tendency 
to  delay  operation  is  great.  Drainage  is  not  used  in  the  serous  cases 
and  is  much  more  sparingly  employed  in  the  purulent  and  fibrinous 
cases  than  formerly,  and  lastly  counterdrainage  through  the  loin  is  a 
final  resort.  In  the  milder  cases  the  tendency  is  to  follow  Morris's 
teaching  of  opening  the  abdomen,  evacuating  much  of  the  exudate, 
closing  it  and  leaving  the  disease  to  nature  and  medicinal  means. 
Suture  is  by  layers,  with  careful  closure  of  all  dead  spaces. 

Aftertreatment. — In  the  immediate  steps  for  from  three  to  seven 
days  the  drains  are  left  alone  and  loosened  without  pulling,  when  they 
give  way  themselves  and  they  are  omitted  when  the  temperature  is 
nearly  normal  and  the  discharge  scanty.  The  outer  dressing  is  kept 
clean  by  frequent  changes  and  a  special  day  and  night  nursing  is 
advisable.  Diet  is  nutritious  and  light  but  sufficient  to  maintain 
strength  and  gradually  increased  with  the  improvement.  Vomiting 
indicates  nutrient  enemata  if  no  diarrhea  prevents.  The  gentle  use 
of  calomel  aids  the  action  of  the  bowel  and  liver,  and  stimulation 
against  absorption  is  required.  The  remote  aftertreatment  observes 
attention  to  the  gonoccocal  focus  and  restores  the  defective  nutrition 
and  depreciated  strength  of  the  patient.  Anemia  is  often  common  for 
long  periods  due  to  the  infection  and  adhesions  and  invalidism  often 
require  late  operations  for  their  relief. 

Cure. — Cure  involves  not  only  saving  the  life  of  the  patient  but  so 
far  as  possible  restoration  of  the  abdominal  contents  to  as  nearly  as 
possible  normal  positions  and  full  physiological  function. 

3.  Circulatory  Complications. 

Occurrence. — The  cardiovascular  system  does  not  escape  gonococcal 
infection.  The  antecedent  focus  is  always  severe  and  profound. 
The  arteries  and  veins  are  not  often  in\'olved.  As  a  less  uncommon 
but  severe  complication,  the  heart,  in  its  valves,  lining,  muscle  and 
sac,  may  be  attacked  at  any  period  of  acute  or  chronic  disease.  These 
lesions  are  beyond  doubt,  as  frequent  autopsies  have  proved  the 
organism  in  the  serous  membrane  and  the  blood.  Luys  reports  at 
least  100  proved  cases  in  literature.^  Males  seem  to  be  more  fre- 
quently attacked  than  females. 

1  Text-book  on  Gonorrhea,  1913,  p.  226. 


224     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

Varieties.— Classification  of  cardiat"  foin])li('atloiis  is,  as  to  site,  endo- 
cardial [the  most  connnon)  and  pericardial  and  myocardial  (the  less 
common  and  almost  always  secondary  to  endocarditis).  All  tliree 
may  occur  as  one  intense  disease  process. 

A.  Cardiac  Complications. 

GONOCOCCAL   ENDOCARDITIS. 

Occurrence. — Endocarditis  is  frequent,  important  and  jjractically 
always  ])riniarv  with  reference  to  myocarditis  and  pericarditis. 

Varieties. — Clinical  subdi\isions  are  primary,  secondary,  acute,  sub- 
acute, chronic,  complicated  and  uncomplicated.  The  valvular  forms 
are  aortic,  mitral,  pulmonary  and  tricuspid. 

Etiology. — A  severe  gonococcal  focus  is  present — urethral,  prostatic 
or  seminal  vesicidar.  The  endocarditis  appears  after  or  during  the 
gonococcal  bacteriemia. 

Pathology.^ — The  suppurative  gonococcal  fo2us  is  essential.  In  the 
heart  are  found  ^'al^'ular  inelasticity,  thickening,  vegetation,  ulcera- 
tion, perforation,  deformity  and  sometunes  thrombi.  INIyocarditis  and 
pericarditis  may  be  associated. 

Symptoms. — Conditions  duplicate  those  of  any  other  septic,  acute 
endocarditis  in  subjective  and  objective  syndromes  and  physical  signs. 
The  termination  is  also  similar. 

Treatment. — The  treatment  is  as  described  at  the  end  of  this  subject 
on  page  230. 

GONOCOCCAL   MYOCARDITIS. 

Clinical  Features. — INIyocarditis  is  always  associated  with  endocar- 
ditis in  occm-rence,  etiology,  pathology,  s\Tnptoms  and  treatment. 

GONOCOCCAL  PERICARDITIS. 

Occurrence. — Pericarditis  is  rarely  primary,  but  usually  secondary  to 

endocarditis. 

Clinical  Features. — Varieties,  pathology,  symptoms,  diagnosis  and 
treatment  (lui)licate  those  of  other  forms  of  this  lesion. 

Diagnosis. — Hecognition  of  the  primary,  septic,  gonococcal  focus  is 
essential,  also  definite,  subjective  and  objective  cardiac  syndrome  with 
complete  laboratory  analysis. 

Differential  Diagnosis. — The  gonococcus  alone  is  the  deciding  factor. 

Treatment. — The  gonococcal  point  of  absorption  must  be  (tiu-ed.  The 
cardiac  conditions  are  managed  the  same  as  those  of  other  types  of 
each  disease. 

B.  Vascular  Complications. 

Varieties. — Aortitis,  phlebitis  and  thrombosis  are  the  three  lesions 
seen  in  gonococcal  septicemia.     All  are  rare  in  occurrence. 


GONOCOCCAL  SEPTICEMIA,  BACTEREMIA  AND  TOXEMIA     225 

AORTITIS,    PHLEBITIS    AND    THROMBOSIS. 

Occurrence. — These  vascular  signs  are  very  unusual  except  in  septic 
bacteremia. 

Pathology. — The  gonococcus  is  added  to  the  common  lesions  of 
acute  inflammation  of  other  origin.  They  are  associated  with  those 
of  the  cardiac  foci  and  the  septicemia. 

Symptoms. — The  characteristic  syndrome  is  present  as  seen  with 
other  infections,  together  with  that  of  the  primary  gonococcal  focus. 

Diagnosis. — Many  cases  requu-e  postmortem  data.  The  primary 
gonococcal  lesion  must  be  proved  and  the  case  recognized  through  its 
symptoms  and  other  laboratory  evidence. 

Treatment. — Original  lesions  must  be  cured.  Cu-culatory  conditions 
are  managed  in  the  usual  ways. 

GONOCOCCAL   SEPTICEMIA,   BACTEREMIA   AND   TOXEMIA. 

Definition. — Gonococcal  septicemia  is  a  condition  induced  by  the 
absorption  of  septic  products  from  a  gonococcal  process;  bacteremia 
is  an  analogous  state  in  which  the  living  gonococci  are  present  in  the 
blood,  and  toxemia  is  a  disease-process  of  the  blood  containing  poison- 
ous products,  due  to  the  growth  of  gonococcus  in  the  blood.  These 
three  terms  are  used  more  or  less  indefinitely  and  interchangeably  to 
denote  generalized  infection  with  the  gonococcus.  The  term  gonococ- 
cemia^  is  sometimes  used. 

Significance. — Gonococcal  septicemia  and  its  analogues,  bacteremia 
and  toxemia,  give  a  new  interpretation  to  gonococcal  infection  founded 
on  the  advances  of  modern  bacteriology  and  hematolog}^  In  the  older 
and  even  best  authorities,  such  as  Taylor,^  in  America,  definite  men- 
tion of  these  lesions  is  entirely  omitted.  Knowledge  of  this  patho- 
logical entity  converts  gonococcal  infection  from  solely  a  local  into 
occasionally  a  systemic  disease,  intrinsically  due  to  the  penetration  of 
the  gonococcus  from  an  antecedent  focal  lesion  into  the  blood  and  its 
circulation  there,  with  secondary  deposit  in  almost  any  organ  or  tissue, 
or  due  to  the  absorption  of  septic  products  and  their  circulation, 
through  the  blood  stream.  In  this  detail  it  duplicates  any  other 
form  of  septicemia  and  its  allies. 

While  strictly  not  a  circulatory  complication,  the  blood  as  an  organ 
is  primarily  and  in  a  sense  preeminently  concerned.  For  these  reasons, 
therefore,  in  this  work  it  is  treated  as  an  involvement  of  the  circulatory 
system. 

Probably  no  extragenital  complications  of  gonococcal  infection  what- 
ever, excepting  such  accidents  as  ophthalmia  which  may  occur  from 
mediate  or  instrumental  transference,  may  arise  without  the  presence 
of  septicemia  or  bacteremia  in  mild  or  severe  degree.    This  rule 

1  A  hybrid  word  gonohemia  meaning  literally  seed  or  semen  in  the  blood,  -which  is  as 
far  as  possible  removed  from  gonococcal  septicemia,  is  sometimes  used  and  vdthout 
etymological  reason  or  excuse. 

*  Loc.  cit. 
15 


22()     COMPLICATIOXS  AND  SEQUELS  OF  ACUTE   URETHRITIS 

undoubtedly  liolds  in  nianitVstations  within  tho  cutaneous,  central  and 
peripheral  nervous  and  locomotory  systems,  as  later  described  and 
exemplified  by  rashes,  meningitis,  neiu-itis  and  neuroses,  myositis, 
arthralgia  and  arthritis,  periostitis  and  the  like. 

All  these  lesions  may  be  embraced  under  the  hemic  classification, 
because  none  can  arise  without  the  action  of  the  bacteria  or  their 
toxins  circulating  in  the  blood  and  primarily  depositing  at  various 
and  numerous  points  and  secondarily  extending.  The  cardiac  foci  are 
therefore  the  ])ericardium,  endocardium  and  the  muscularis,  and  the 
vascular  locations  are  the  chief  trunks  of  the  aorta  and  veins  followed 
by  thrombosis  and  the  hemic  site  is  tlie  blood  itself  regarded  as  an 
organ  with  a  fluid  matrix  and  floating  cells.  Arthritis  belongs  to  the 
same  class  but  is  discussed  in  itself,  likewise  metastatic  abscess. 

That  gonococcal  infection  as  a  cause  of  death  is  not  a  medical  curi- 
osity is  shown  by  numerous  thoroughly  diagnosticated  cases  in  litera- 
ture. Examples  of  such  rei)orts  are  the  following:  Brewer^  has  noted 
a  case  of  fatal  gonorrheal  infection  with  autopsy  report;  Cornell^ 
describes  a  case  of  gonorrhea  rendered  fatal  by  its  sequelje;  Fenwick^ 
has  observed  a  case  of  gonorrhea  ending  fatally;  Kossmann^  has  seen 
two  cases  of  death  in  consequence  of  gonorrhea;  Post^  saw  one  patient 
die  directly  from  the  gonorrhea,  and  Robinson''  discusses  systemic 
infection  from  gonorrhea  with  report  of  a  fatal  case. 

Occurrence. — In  general  frequency,  septicemia  is  rare  when  com- 
pared with  the  vast  number  of  gonococcal  sexual  involvement  in  men, 
women  and  children.  Never  primary  but  always  secondary  to  such 
genital  lesions,  it  is  more  frequent  in  males  than  in  females,  in  pregnant 
than  nonpregnant  women,  and  in  children  than  adults.  Males  suffer 
most  doubtless  through  the  greater  incidence  of  the  disease  upon  this 
sex  in  the  general  nature  of  their  social  relations,  while  low  resistance  is 
doubtless  at  work  in  pregnant  women  and  children.  It  is  more  common 
in  posterior  than  in  anterior  urethral  disease,  and  in  complicated  than 
uncomplicated  cases,  although  initial  anterior  disease  has  been  known 
to  cause  it.  Of  the  complications  the  extraurethral  lesions,  such  as 
prostatitis,  seminal  vesiculitis  and  epididymoorchitis  in  the  male,  and 
salpingitis  and  ovaritis  in  the  female  predominate  in  its  occurrence, 
and  not  uncommonly  in  old  rather  than  recent  cases,  in  which  subjec- 
tive symptoms  may  be  practically  absent. 

Varieties. — Varieties  co\er  the  major  subdivisions  of  the  hemo- 
poietic system  as  shown  in  the  clinical  section  but  their  treatment 
had  best  be  considered  under  septicemia,  bacteremia  and  toxemia, 
because  it  is  ob\'ious  that  none  of  them  can  arise  without  these  basal 
conditions.  The  cardiac  lesions  are  endocarditis,  pericarditis  and  myo- 
carditis, the  vascular  invasions  are  aortitis,  phlebitis  and  thrombosis, 

1  .lour.  Cutan.  and  Gen.-Urin.  Dis.,  1897,  xv,  260. 

2  Montreal  Med.  Jour.,  1900,  xxix,  100. 

3  British  Med.  Jour.,  1899,  ii,  1.544. 

*  Miinchen.  med.  Wchnschr.,  1900,  xlvii,  .39.5. 
6  Boston  Med.  and  Surg.  .Jour.,  1887,  cxvi,  417. 
«  Med.  News,  1890,  Ixix,  230. 


GONOCOCCAL  SEPTICEMIA,  BACTEREMIA  AND  TOXEMIA     227 

and  the  hemic  disease  is  tUc.  septicemia,  bacteremia  and  toxemia. 
Metastatic  abscess  belonjijs  in  this  class,  })ut  is  sei)arat(;ly  discussed  for 
convenience.  Arthritis  is  in  a  class  by  itself  also,  but  Ixjlon^s  to  this 
general  group  of  lesions  dependent  on  the  circulation  of  bjictcria  ;ind 
their  toxins  in  the  blood. 

Etiology. — 'i'he  factors  are  predisposing  and  exciting,  systemic  and 
local.  The  predisposing  elements  are  lowered  general  vitality,  shown 
by  a  naturally  poor  resistance  to  most  diseases,  a  history  of  which  is 
commonly  obtainable,  or  from  the  actual  presence  of  such  systemic 
disease  as  diabetes,  nephritis,  syphilis  and  tuberculosis,  and  likewise 
lowered  local  vitality  due  to  rough  instruments,  unskilful  application  of 
instruments,  and  congestion  from  venereal  excess,  alcoholism,  concen- 
trated solutions,  and  undue  frequency  or  activity  of  treatment. 

The  exciting  cause  is  regularly  the  gonococcus  either  in  pure  infec- 
tion or  associated  with  other  organisms  of  the  pyogenic  species,  notably 
the  streptococcus,  staphylococcus,  and  the  Bacillus  coli  communis, 
which  add  to  the  seriousness  of  the  case.  It  seems  that  as  long  as  the 
gonococcus  persists  in  active  or  chronic,  anterior  or  posterior,  com- 
plicated or  uncomplicated  urethritis,  septicemia  may  at  any  moment 
suddenly  appear,  with  or  without  assignable  cause.  The  ports  of 
entrance  are  in  the  mucosa,  points  of  denudation,  or  ulceration  through 
the  inflammation,  or  of  traumatism  through  instrumental  or  other 
treatment,  and  are  in  the  organs  involved  in  any  complication  or  in  local 
destruction  or  abscess  formation  of  even  minute  size  and  chronic  type. 
It  is  peculiar  that  so  few  cases  of  gonococcal  septicemia  occur  in  the 
ordinary  circumstances  and  course  of  the  disease  so  that  one  may  say 
that  perhaps  the  organism  does  not  usually  thrive  in  the  blood  stream. 
If  this  were  otherwise  metastases  containing  the  gonococcus  would  be 
the  rule  instead  of  the  strange  exception.  Hematology  will  later 
decide  this  point. 

The  basis  of  the  complications  of  septicemia,  bacteremia  and  toxemia 
is  therefore  the  presence  of  the  gonococcus  or  its  products  or  both 
within  the  bloodstream  and  their  diffusion  through  the  body.  Three 
avenues  of  origin  are  described:  that  is,  hemic  and  lymphatic,  involving 
perhaps,  chiefly  the  bacteria  themselves,  and  toxic  involving,  perhaps, 
mostly  the  products  from  the  antecedent  condition  or  source,  or  from 
the  growth  of  the  organism  after  reaching  the  blood,  or  after  its  deposit 
in  various  remote  organs.  The  order  of  frequency  of  these  origins  is, 
as  stated,  hemic,  lymphatic  and  toxic.  Thayer  and  Blumer^  were  the 
first  to  prove  during  life  pure  cultures  of  the  gonococcus  in  the  blood, 
while  Uysing^  followed  by  demonstrating  it  in  the  hinphstream. 
Such  proofs,  however,  are  most  difflcult  even  in  the  presence  of  active 
septicemia,  probably  because  the  organisms  are  not  numerous,  relative 
to  the  bulk  of  the  blood,  and  through  their  tendency  to  penetrate 
tissue  they  may  still  further  undergo  apparent  reduction  in  nmiiber; 

1  Arch,  de  med.  exper.  et  d'anat.  path.,  Paris,  November,  1895.      Johns  Hopkins  Hosp. 
Bull.,  1896,  \di,  57. 

2  Inaug.  Dissert.,  Kiel,  1900. 


228     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

and  furtheniu)ro,  the  tochnical  tliflieulty  of  cultivatiiii;- the  gouococcus, 
especially  Avlieii  present  in  mixed  infection,  cannot  be  o\erlooked  as 
an  obstacle.  These  factors  excite  the  circumstance  of  difficulty  rather 
than  facility  in  findins;  the  organism,  although  it  grows  best  in  media 
containing  human  blood  serum. 

Pathology. — Primary  cases  of  gonococcal  sei)ticemia  are  unknown, 
as  this  ct)mplication  and  its  allies  is  always  a  consequence  of  urethral 
or  other  local  infection.  The  pathogenesis  does  not  diti'er  in  any  mate- 
rial detail  from  that  of  se])tieemia  from  any  other  organism  and  its 
l)roducts.  The  essence  of  the  j)rocess  is  the  circulation  in  the  blood  of 
the  gonococcus  with  its  septic  and  toxic  products,  after  a  ])ort  of  entry 
has  been  created  on  the  surface  of  the  mucosa,  within  the  substance 
of  a  gland  like  the  prostate  or  the  cavity  of  an  organ  like  tlie  seminal 
vesicle  or  Fallo})ian  tube,  through  inflammatory  or  accidental  factors  or 
both.  The  organs  and  tissues  in^'ol^'ed  hiclude  all.  None  escape, 
although  most  commonly  the  serous  membranes  are  first  and  chiefly 
involved,  perhaps  through  their  structural  analogy  with  tlie  mucous 
membranes.  Thus  there  are  found  in  the  circulatory  system  endo- 
carditis and  ])erlcarditis;  in  the  respiratory,  ])leuritis;  in  the  digestive, 
peritonitis;  in  tiie  nervous,  meningitis;  and  in  the  locomotory  system, 
arthritis  and  tenosjuovitis.  The  "meninges  are  not  serous,  but  delicate 
and  susceptible  tissues.  Temporary  lesions  may  be  said  to  occur  only 
in  the  least  involved  tissues  and  m  cases  of  recovery  which  seem  to 
comprise  about  two  in  every  three  cases.  Permanent  changes,  however, 
are  very  common  in  the  serosae  attacked,  and  the  associated  lesions  are 
naturally  the  antecedent  condition  or  complication,  and  finally  the 
bacteriology  is  always  the  gonococcus  alone  or  in  associated  ijifec- 
tion. 

Symptoms. — As  in  other  septicemia,  that  caused  by  the  gonococcus 
has  a  various  and  uncertain  symptom-complex,  with  on  the  whole 
no  new  features,  and  indistinguishable  from  such  other  septicemia, 
excepting  ]:)y  hematology  and  the  history  of  localized  antecedent  gono- 
coccal iuAolvement,  uncomplicated  or  complicated,  acute  or  chronic. 
Subjective  symptoms  in  the  strict  sense  are,  excepting  rarely  in  mild 
cases,  absent.  The  patients  are  too  ill  in  severe  cases  in  degree  and  the 
disease  is  too  rapid  in  progress  to  permit  a  subjective  picture.  The 
o})jective  s\Tnptoms,  on  the  other  hand,  predominate  and  vary  widely 
in  their  constancy,  association  and  degree.  Periods  of  invasion, 
establishment  and  termination  may  be  distinguished  usually  by 
systemic  less  often  than  by  local  conditions.  The  latter  are  commonly 
foci  of  the  deposit  or  infarct  in  some  important  organ  or  system,  as 
part  of  the  general  septicemia  and  Imcteremic  process,  and  constitute 
practically  a  new  group  of  complications  of  extragenital  type,  such  as 
endocarditis,  meningitis,  and  arthritis,  as  examples.  No  description 
may  be  given  for  all  cases  and  reports  in  literature  emphasize  the  pre- 
dominance of  one  s^'mptom  over  another  largely  in  accordance  with 
this  element  of  infarct.  All  the  sjTnptoms  are,  therefore,  elements  of  a 
general  systemic  disease,  while  definite  syndromes  mark  the  invasion 


GONOCOCCAL  SEPTICEMIA,  BACTEREMIA  AND  TOXEMIA    229 

of  a  given  system  preeminently  over  other  systems.  'J^he  general  course 
may  be  mild,  severe  or  intense. 

The  period  of  invasion  is  usually  accompanied  by  sudden  decrease 
or  even  cessation  in  the  local  symptoms,  such  as  a  urethritis  or  one  of 
its  active  complications,  or  the  invasion  may  suddenly  issue  out  of  a 
clear  sky,  that  is,  during  the  seeming  absence  of  any  local  activity. 
There  are  commonly  chill  and  chilliness,  a  sudden  high  fever  with  wide 
variations,  or  a  moderate  fever  of  more  or  less  constant  range  (accord- 
ing to  the  resistance  of  the  patient)  with  profuse  i>erspiration  and 
digestive  disturbance.  After  establishment  the  symptoms  continue  and 
commonly  augment.  The  perspiration  is  followed  by  sudamina,  or  a 
variously  papular  eruption  containing  the  gonococcus.  The  digestive 
disorder  is  nausea,  vomiting,  diarrhea  or  constipation,  all  of  moderate 
or  severe  degree.  The  fever  is  of  the  true  septic  type,  low  in  the  morning, 
high  at  night,  with  wide  differences,  or  more  constant  in  its  average 
and  much  less  in  its  range.  The  nervous  system  at  first  is  stimulated 
into  active  delirium  and  then  depressed  into  stupor,  coma  and  death. 
The  circulatory  system  early  shows  cardiac  weakness,  disturbance 
and  insufficiency.  Splenic  and  hepatic  enlargement  have  been  noted. 
Except  in  the  cases  of  short  duration  and  fatal  outcome  emaciation 
and  anemia  are  profound.  Protracted  cases  may  show  carphology, 
low  muttering  delirium,  subsultus  tendinum  and  finally  wasting  death. 
The  blood  test  reveals  the  gonococcus  alone  or  with  associated  organ- 
isms in  the  blood,  leukocystosis  of  from  ten  to  thirty  thousand,  and 
anemia.  The  kidneys  reveal  various  forms  and  degrees  of  acute 
nephritis  usually  with  exudation  of  albumin,  casts,  blood  and  pus. 

The  objective  local  symptoms  of  the  foci  of  deposit  and  infarct  may 
complicate  the  picture  at  any  time,  and  distract  the  attention  from  the 
general  to  such  local  manifestations.  Thus  the  chief  symptoms  may 
be  due  to  the  endocarditis,  pericarditis,  arthritis,  pleuritis,  pneumonia 
or  meningitis,  which  in  its  turn  is  very  difficult  to  distinguish  in  its 
symptoms  from  those  due  to  the  septicemia  itself. 

The  terpaination  is  fatal  in  only  30  per  cent,  of  cases,  according  to 
Luys,^  but  cases  favorable  at  first  may  later  have  a  lethal  issue.  The 
outlook  for  health  is  otherwise,  especially  when  any  of  the  CDmplica- 
tions  produced  by  the  septicemia  arise  as  just  stated.  Relapses  are 
not  uncommon  as  might  be  expected  from  the  natm'e  of  the  chronic 
foci  from  which  these  cases  often  arise.  The  most  serious  cases  are 
those  with  cardiac  involvement  as  few  escape  without  materially 
damaged  valves.  Cases  with  recovery  usually  have  a  slow  coiu-se  until 
good  health  is  restored.  The  mild  cases  result  in  full  recovery.  In 
fact,  it  has  been  shown  that  a  few  cases  of  gonococcal  urethritis  have 
the  organisms  circulating  in  the  blood  without  active  septicemia. 

Diagnosis. — The  only  facts  in  the  history  are  that  the  s\Tnptoms  arose 
during  the  course  of  acute  vicious  gonococcal  lu-etlu'itis  or  at  the  onset 
of  acute  complications  or  in  the  exacerbation  of  chronic  urethritis  and 

1  Loc.  cit.,  p.  35. 


230     COMPLlC.VriOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

its  complications  ami  even  varclx'  in  the  midst  of  (luicsccut  conditions 
with  nnex})lained  canse. 

Inasmnch  as  the  snhjectixo  symi)toms  chipHcatc  tliosc  crt'  scpticcMnia 
from  other  organisms,  bacteriological  research  will  alone  distingnish 
the  gonococcal  form  from  all  other  forms  and  will  require  isolation  and 
culture  of  the  gonococcus  from  the  blood  and  from  such  foci  -as  may 
ai)i)ear  in  the  skin,  joints  and  the  like.  For  objective  signs  it  is  well 
to  search  the  urogenital  organs  in  males  and  females  for  an  unsus- 
pected and  nu)re  or  less  active  and  even  comparatively  inactive  focus. 
The  presence  of  such  a  lesion  in  acti\'e  form  should  at  once  attract 
attention.  Laboratory  proof  is  essential.  It  has  been  suggested  that 
the  moments  of  intermission  and  remission  in  the  fever  of  septicemia 
are,  as  in  malaria,  the  best  times  for  looking  for  the  organisms  in  the 
blood.  The  gonococcal  complement  deviation  test  is  still  in  its  develop- 
ment, but  should  never  be  omitted  in  these  cases.  It  is  perhaps  par- 
ticularly helpful  in  the  female  in  whom  so  many  unsus])ected  deposits 
of  the  disease  occur.  It  thus  follows  that  in  many  patients,  males  or 
females,  a  clinical  cure  is  reached  before  a  serological  cure,  a  fact  which 
only  emphasizes  the  importance  of  serology  in  this  antl  allied  diseases. 
Treatment  is  not  an  aid  in  the  diagnosis  except  as  it  may  uncover  and 
relieve  an  obscure  focus  of  origin  of  the  absorption  and  furnish  suitable 
exudate  and  specimens  for  the  pathologist. 

Differential  Diagnosis  rests  almost  solely  on  identification  of  the 
gonococcus  in  discharge,  exudate  or  secretion  of  sexual  glands  and 
circulating  in  the  blood  and  on  the  complement  fixation  test  for  its 
presence  in  the  system. 

Treatment. — To  larger  works  on  general  surgery  and  medicine  is 
resigned  the  amplified  treatment  of  septicemia  but  the  following 
suggestions  are  of  great  value.  Prophylaxis  ofi'ers  no  direct  relief,  as 
the  patients  show  low  resistance,  early  bacterial  and  toxic  absorption 
and  their  results.  Indirect  prevention,  however,  underlies  the  best 
possible  conservative  treatment  of  severe  gonococcal  lesions  and  the 
evacuation  of  pus  foci,  such  as  abscesses  in  the  seminal  vesicles  and 
prostate.  Abortion  is  ipso  facto  impossible  because  the  disease  is 
well  established  at  the  earliest  possible  symptom. 

Chapter  IX  on  General  Principles  of  Treatment  explains  the  essen- 
tials of  management  on  page  483. 

Physical  measures  cannot  be  applied  in  the  acute  stages  as  the 
patients  are  too  sick  and  the  character  of  these  measures  tends  to  dis- 
turb quiescent  foci.  In  hydrotherapy  liDt-packs  for  elimination  through 
the  skin  and  support  of  the  kidneys  are  valuable  and  enterocl}'sis 
adds  stimulation  of  the  circulation,  cleansing  of  the  blood  through 
absorption  and  probably  elimination  by  bowel,  kidneys  and  skin.  In 
the  chronic  period  of  sur\iving  cases  as  passi\-e  muscular  activity 
massage  is  ad\'ised  and  hydrotherapy  for  stimulation  and  elimination 
and  for  the  treatment  of  some  focal  disease  such  as  the  remnant  of  the 
original  complication. 

The  heliotherapy  is  actinic,  thermic  and  eliminant  in  its  function 


GONOCOCCAL  HEl'TICEMIA,  BACTEREMIA  AND  TOXEMIA     231 

for  selected  cases  and  is  ai)i>lied  with  a  500  c.j).  lamp  with  a  suitable 
reflector  travellhig  slowly  over  the  surface  in  the  manner  described 
under  Peritonitis,  page  220.  The  duration  is  from  a  half  to  one  hour 
at  each  sitting  and  its  frequency  is  several  times  a  day,  and  in  an 
institution  even  oftener.  Alternation  with  electrotherapy  is  well.  Its 
results  are  intense  hyperemia,  relief  of  vascular  spasm,  nervous  irrita- 
tion and  pahi  and  increased  phagocytosis. 

The  electrotherapy  consists  solely  in  diathermy  on  local  manifesta- 
tions or  foci  in  any  organ.  The  electrodes  must  be  each  of  the  same 
size,  never  smaller  than  twelve  square  inches  in  area  (3  x  4  inches), 
and  must  be  placed  at  opposite  sides  of  the  affected  area  so  that  the 
lesion  shall  be  as  far  as  possible  fully  within  the  field  of  the  electrodes. 
The  current  is  4  to  5  milliamperes  and  no  more  and  the  duration  is 
from  ten  to  twenty  minutes  with  a  frequency  of  daily  at  first  and  later 
three  times  a  week  until  relieved.  With  skill  there  is  no  unfavorable 
reaction,  but  small  electrodes  will  cause-  burns.  Alternation  with 
heliotherapy  is  of  value  and  should  be  the  usual  procedure. 

The  medicinal  measures  are  in  the  acute  period  very  important,  but 
usually  of  little  avail.  On  account  of  the  negative  phase,  serum- 
therapy  is  rather  risky,  as  it  may  only  add  to  fatalities.  Small  doses, 
carefully  watched,  are  to  be  tried  if  at  all.  By  systemic  administration, 
stimulation,  support,  sedation  and  elimination  are  the  methods. 
Quinin  is  often  good  as  antiseptic  and  febrifuge  and  no  stimulant  is 
better  than  alcohol  as  whisky,  champagne  and  port  wine.  It  is  an 
easily  oxidizable  food  in  these  cases  and  is  given  short  of  intoxication. 
Strychnin  is  p-n  excellent  nervous  and  circulatory  support  and  mor- 
phin  is  indispensable  for  pain,  restlessness  and  insomnia,  with  caution 
not  to  mask  other  symptoms.  Elimination  through  the  bowel  and  skin 
must  never  be  neglected. 

In  reference  to  special  organs  and  systems  of  the  body  as  attacked 
require  treatment  so  minute  that  the  reader  is  referred  to  large  works 
on  general  medicine  for  it.  The  general  principles  are,  however,  men- 
tioned under  appropriate  headings:  Acute  and  chronic  endocarditis, 
myocarditis  and  pericarditis  are  detailed  under  cardiac  complications, 
aortitis,  phlebitis  and  thrombosis  are  discussed  under  vascular  sequels 
of  gonococcal  disease,  while  metastatic  abscess  and  arthritis  are 
reserved  for  separate  attention  on  pages  235  and  248. 

Other  general  principles  of  treatment  are  important.  The  bowels 
must  be  evacuated  through  cathartics  by  mouth  and  enemata  into  the 
rectum  and  lower  colon.  The  condition  of  the  gastric  and  recto- 
colonic  mucosa  determines  tolerance  for  the  drugs  administered  and 
the  results  of  treatment.  Cathartics  of  value  are  the  following: 
Calomel,  in  yV-grain  doses,  every  quarter-hour,  or  in  J-grain  or  ^- 
grain  doses  every  half  hour,  until  the  bowels  begin  to  move,  may  be 
tried.  Soft  capsules  of  castor  oil,  drams  1  to  2,  may  be  repeated  until 
evacuation  occurs,  if  the  patient  can  swallow  them.  Magnesium 
sulphate  or  magnesium  citrate,  from  1  teaspoonful  to  1  wineglassful,  at 
quarter  or  half-hour  intervals,  is  a  good  adjuvant  of  the  calomel  after 


232     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

its  liuiit  has  been  rcaclicd.  One  or  two  drops  of  crotoii  oil  may  be  added 
to  one  administration  of  the  other  cathartics  if  ileus  is  threatened  in  a 
case  of  sejiticemia  Avith  })eritouitis. 

The  enomata  may  be  A\arm  normal  salt  solution  which  by  its  bulk 
stimulates  the  bowels  to  mo^•e  or  soapsuds  combined  with  oxgall, 
tur])entine,  Epsom  salts  and  similar  stimulants  of  peristalsis  according 
to  inilication.  Slow  administration  is  the  secret  of  colonic  eneraata, 
which  are  often  necessary  before  a  result  is  reached. 

Direct  absorption  hito  the  circulation  of  corrigents  of  the  infection 
may  be  secured  by  inunction  and  intravenous  injection.  The  unguen- 
tum  argenti  colloidalis  of  Crede'  may  be  rubbed  into  the  skin  in  1 
dram  doses  once  a  day  and  the  intravenous  injection  of  2  per  cent, 
emulsio  argenti  colloidalis  may  be  given  once  a  day  to  the  limit  of 
15  grains.  The  inunctions  and  intravenous  injections  may  alternate  by 
daj's  or  by  longer  periods. 

The  dilution  and  elimination  of  the  poisons  by  the  kidneys  is  secured 
by  the  intake  of  large  quantities  of  fluid  by  any  of  the  following  methods. 
The  Murphy  drip  is  of  great  service  and  may  be  applied  for  periods  of 
one  to  two  hours,  with  a  period  of  rest  between.  Normal  salt  solution 
is  the  fluid  and  the  rectal  tube  is  gently  passed  as  high  up  the  bowel  as 
possible.  When  tolerance  of  this  method  fails  small  eneraata  of  normal 
salt  solution  may  be  run  into  the  bowel  every  two  to  foiu*  hours  and 
retained  by  the  i)atient.  Free  water  drinking  is  likewise  of  value  for 
this  pm-pose  when  the  stomach  tolerates  it. 

The  siugical  measiues  are  nonoperati^'e  and  operative,  of  which,  of 
course,  the  latter  are  by  all  means  the  most  important.  The  non- 
operative  details  differ  in  no  respect  from  the  means  already  spoken 
of  under  medicinal  measures.  The  management  of  dressings  is  also 
important.  The  dressings  and  drains  should  be  at  once  removed  if 
there  has  been  an  operation,  such  as  for  prostatic  abscess,  to  cleanse  the 
wound,  evacuate  accumulated  pus  and  exudate  and  otherwise  remove 
a  source  of  absorption  through  this  path.  No  subsequent  dressings 
or  drains  must  again  repeat  such  retention. 

The  operative  measures  are  major  and  minor  operations,  dependent 
entirely  on  the  nature  and  extent  of  the  ])rimary  nidus  and  the  acces- 
sibility of  the  secondary  septicemic  foci. 

Among  the  rahior  operations  are  to  be  mentioned  the  free  opening, 
evacuation,  drainage  and  dressings  of  abscesses,  the  infusion  of  normal 
salt  solution  under  the  skin  or  its  injection  into  a  vein  and  the  trans- 
fusion of  blood.  The  technics  of  all  these  ])rocedures  are  so  familiar 
that  they  will  be  omitted  here.  The  intravenous  injection  of  2  per  cent, 
magnesium  sulphate  in  |  to  1  pint  doses  daily  for  days  or  of  2  per  cent, 
emulsion  of  colloidal  silver  (Crede),^  in  15-grain  doses  daily,  for  several 
days,  belongs  in  this  category.  A  needle  is  simply  passed  into  the  vein 
exactly  in  the  .method  followed  in  the  administration  of  salvarsan. 

The  major  operations  are  attacks  on  all  accessible  foci  of  infection 

1  XII  Congr6s  intemation.  de  m^decine,  Moscow,  1897,  v,  349.  ^  Lqc.  cit. 


GONOCOCCAL  SEPTICEMIA,  BACTEREMIA  AND  TOXEMIA    233 

which  must  be  evacuated  to  prevent  further  absorption.  Involved 
joints  are  opened  and  drained,  abscesses  of  the  glands  of  Cowper,  the 
prostate  and  the  seminal  vesicles  in  the  male  and  the  vulvovaginal 
glands,  the  uterus  and  tubes  and  ovaries  in  the  female  must  all  be 
freed  of  accumulated  pus.  Hysterectomy  and  curetting  are  methods 
of  dealing  with  an  infected  uterus  according  to  severity  of  the  lesion . 
In  peritonitis  as  a  lesion  of  the  septicemia  a  rapid  laparotomy  is  indi- 
cated with  judicious  irrigation  by  the  return  flow  method  of  all  pockets 
followed  by  thorough  mopping  out  and  multiple  drainage  and  finally 
by  the  use  of  Fowler's  position.  The  exact  technic  of  all  these  opera- 
tions belongs  to  works  on  general  surgery.  If  an  operation  has  been 
done  stitches  must  be  removed  and  the  wound  cleansed  of  even  trifling 
foci  of  pus  because  it  must  be  remembered  that  many  of  the  most 
intense  infections  have  little  accumulation  of  pus  about  the  wound. 
It  must  be  remembered  that  in  generalized  peritonitis  of  severe  type 
little  treatment  is  of  avail  and  that  death  is  prompt  and  dreadful  from 
the  suffering  of  the  patient.  On  the  other  hand,  localized  peritonitis  of 
the  pelvic  type,  especially  in  women,  is  a  hopeful  disease  when  treated 
promptly  and  well  in  accordance  with  the  foregoing  methods.  In 
general,  gonococcal  peritonitis  is  less  severe  than  that  due  to  the  strep- 
tococcus and  the  staphylococcus.  When  combined  with  the  latter, 
however,  it  becomes  equally  deadly. 

In  localized  foci  treatment  succeeds  well  as  the  evacuation  of 
abscesses,  the  removal  of  stitches  and  the  cleansing  of  wounds  all 
followed  by  the  application  of  the  tincture  of  iodin  and  the  insertion 
of  an  alcohol  wet  di-essing. 

Intravenous  Injections  of  Magnesium  Sulphate. — This  method  is 
limited  in  literature  to  streptococcic  bacteremia.  Harrar^  reports  a 
number  of  remarkable  results  of  these  injections  when  admuiistered 
to  patients  suffering  from  living  organisms  circulating  in  the  blood- 
stream. This  method  is  inserted  here  in  this  work  because  a  certain 
number  of  systemic  infections  during  gonococcal  lesions  are  associated 
with  the  streptococcus.  It  is  possible  that  this  method  may  be  of 
value  when  organisms  other  than  the  streptococcus  are  circulating  in 
the  blood. 

As  described  by  Harrar  the  following  details  are  embraced  in  the 
technic  of  the  injections:  "A  2  per  cent,  solution  of  chemically  pure 
magnesium  sulphate  is  prepared  with  freshly  distilled  water.  This  is 
filtered  and  sterilized  in  half-liter  flasks  in  an  autoclave.  This  solution 
will  not  hemolyze  human  red  blood  cells,  and  I  have  found  by  expe- 
rience that  prepared  in  this  way  it  will  not  cause  any  temperature 
reaction  in  the  patient.  Formerly  a  1  per  cent,  solution  of  magnesiiun 
sulphate  in  physiological  salt  solution  was  employed,  and  a  chill  or 
sharp  temperature  rise  frequently  followed  the  injection.  A  simplified 
salvarsan  apparatus  is  preferable  for  the  injection  but  the  ordinary 
infusion  set  will  answer  the  pm-pose  quite  as  well.    It  is  important  not 

1  Am.  Jour.  Obst.  and  Dis.  of  Women  and  Children,  1913,  lx\dii.  No.  5. 


234     COMPLICATIONS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

to  cut  (Icnvn  upon  the  vessel,  as  l>y  direct  puncture  the  same  vein  can 
be  used  a  nuniher  of  times.  As  many  as  eiii;lit  punctures  of  the  same 
vein  liave  l>een  nuide  on  (Htl'eriMit  occasions.  The  secret  in  j^etting 
into  the  vein  is  to  make  it  markedly  })rominent.  This  is  (U)ne  by 
temporarily  placing  a  constricting  rubber  tube  about  the  upper  arm 
just  tightly  "enough  that  the  faintest  pulsation  may  still  be  felt  in  the 
radial  artery.  If  the  constriction  about  the  upi)er  arm  is  too  tight, 
the  arterial  as  well  as  the  venous  circulation  will  be  cut  oii"  and  the 
vein  will  not  distend  with  blood.  The  needle  is  inserted  in  an  oblique 
direction,  the  spurting  of  blood  from  the  open  end  indicating  proper 
entrance  into  the  xem.  The  rubber  tube  of  the  reser\'oir  with  the 
solution  Howing  is  then  rapidly  slii)ped  over  the  shoulder  of  the  needle. 
The  reser\oir  is  held  at  not  more  than  one  foot  ele^■ation,  which  will 
run  in  400  c.c.  of  the  solution  in  about  twenty-minutes.  The  injection 
should  be  made  much  more  slowly  than  the  ordinary  saline  infusion. 

"The  patient  ex])eriences  a  sensation  of  heat  toward  the  end  of  the 
injection,  and  frequently  feels  faint,  although  the  pulse  usually  gains 
in  quality'.  A  small  drink  of  hot  whisky  or  aromatic  spirits  of  ammonia 
will  steady  her.  Occasionally  the  respiration  assumes  a  sighing  equality, 
but  no  decrease  in  rate  or  in  depth  of  the  respirations  has  been  observed. 
It  is  quite  evident  that  the  dangers  are  not  so  marked,  the  drug  is 
not  so  toxic,  when  given  intravenously,  as  when  em})loyed  intra- 
spinously  where  it  is  applied  directly  to  the  nerve  tissue.  I  have  given 
as  much  as  400  c.c.  of  a  2  per  cent,  solution  intra^'enously  simul- 
taneously with  400  c.c.  by  hypodermoclysis,  representing  10  grammes 
or  250  grains  of  the  drug,  with  no  alarming  effects.  Whereas  by  intra- 
spinous  injection  for  the  production  of  anesthesia,  or  in  the  treatment 
of  tetanus,  IMeltzer^  advises  1  c.c.  of  a  25  per  cent,  solution  per  20 
pounds  of  body  weight,  or  about  25  grains  for  a  130-pound  individual, 
as  the  safe  limit.  The  injections  should  be  repeated  every  second  or 
third  day  according  to  the  course  of  the  infection  as  revealed  by  the 
temperature  chart. 

"The  method  has  now  been  employed  in  fourteen  cases  at  the  Lying- 
in  Hospital.  In  five  of  these  there  was  a  streptococcic  bacteremia  as 
proved  by  blood  culture.  The  other  nine  were  all  severely  infected 
women  with  high  temperatiu-e  and  acutely  ill  with  streptococcic  toxemia, 
with  pure  growth  of  streptococci  on  uterine  culture,  but  with  negative 
blood  cultures." 

As  already  stated,  it  is  more  than  probable  that  this  method  will  be 
of  great  value  in  cases  of  gonococcic  septicemia  of  the  mixed  type  with 
the  streptococcus  as  one  of  the  invaders.  His  series  of  patients  Harrar^ 
estimates  as  now  fifteen  or  twenty  cases  of  proved  bacteremias,  with 
success  in  about  50  per  cent.,  without  looking  up  actual  records.  He 
recently  employed  it  in  a  case  of  colon  bacillemia  with  prompt  im- 
provement after  one  infusion  and  disap])earance  of  the  bacilli  from 
the  blood  in  a  very  ill  woman  with  pyelonephritis  of  pregnancy. 

»  Jour.  Pharm.  and  Exp.  Thcrap.,  1909-10,  vii. 

2  Personal  letter  to  the  author,  December  18,  1916. 


GONOCOCCAL  METASTATIC  ABSCESS  235 

The  effects  of  the  injections  are  an  air  hunger  if  the  fhiid  is  too 
rapidly  administeretl.  The  first  dose  is  usually  followed  by  a  fall  in 
the  temperature  and  by  a  decrease  in  the  number  of  orj^aiiisms  in  the 
next  blood  specimen.  If  such  second  l)]ood  culture  is  sterile  no  otln-r 
injection  is  given.  If,  on  the  otiier  hand,  there  is  no  improvement  in 
the  clinical  condition  or  in  the  blood  examination  the  injections  are 
repeated,  every  second  day,  with  no  ill  effects  if  care  is  exercised  as  to 
all  the  details.  Harrar  in  a  personal  letter  to  the  author  states  that  he 
has  given  fifteen  injections  on  one  case  and  that  the  average  is  from 
two  to  seven  injections. 

In  his  article  Harrar  draws  the  following  conclusions : 

1.  In  the  quantities  and  dilutions  described,  magnesium  sulphate  is 
absolutely  harmless  when  administered  intravenously  to  women  suffer- 
ing with  puerperal  infection. 

2.  Magnesium  sulphate  is  of  more  value  early  in  the  course  of  the 
infection  than  after  secondary  localization  has  occurred.  In  the  chronic 
cases  of  secondary  thrombophlebitis  or  pyemia  it  does  not  appear 
to  be  of  benefit.  Its  action  seems  to  be  chiefly  upon  the  organisms 
circulating  in  the  blood. 

3.  It  shortens  the  course  of  the  bacterial  toxemias  in  w'hich  the 
bacteria  cannot  be  demonstrated  in  the  blood  by  culture,  and  antici- 
pates the  establishment  of  a  bacteremia. 

4.  It  has  reduced  our  mortality  in  puerperal  bacteremia,  especially 
in  streptococcemia,  the  most  fatal  form  of  puerperal  infection,  from 
93  per  cent,  to  20  per  cent. 

Ajtertreatment. — When  the  patient  survives  all  immediate  measures 
are  directed  to  the  care  of  the  surgical  procedures  necessary  for  the 
heroic  combat  with  the  disease.  The  remote  aftercare  continues 
attention  to  the  kidneys,  which  may  otherwise  .pass  into  chronic 
nephritis,  and  to  the  circulation  and  the  blood,  lest  similarly  the  cardiac 
muscle  be  damaged  and  anemia  of  troublesome  type  supervene.  Sequels 
from  organs  damaged  by  operation  or  the  disease  must  also  be  corrected 
and  in  short  chronic  invalidism  avoided. 

Cure. — Relief  of  the  infection  in  the  immediate  present  and  restora- 
tion of  health  in  the  early  future  are  the  standard  of  cm-e.  Pathologi- 
cally, removal  of  all  lesions  is  often  impossible  but  symptomatically 
the  patient  may  live  for  years  in  comparative  or  absolute  good  health. 

GONOCOCCAL  METASTATIC  ABSCESS. 

Significance. — The  abscess  is  a  sign  of  acute  or  chronic  septicemia 
and  absorption  manifested  as  a  cutaneous  or  visceral  deposit  and  as  a 
proof  of  the  seriousness  of  the  septicemia. 

Occurrence. — True  metastatic  abscess  as  a  sjTnptom  of  gonococcal 
septicemia  or  bacteremia  is  of  rare  appearance.  It  is  not  possible  for 
it  to  arise  in  any  other  manner.  The  site  of  such  abscesses  may  on 
theoretical  grounds  be  in  almost  any  organ  but  those  reported  in  litera- 
ture are  chiefly  in  the  skin,  or  organs  opening  from  the  skin. 


230     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

Etiology. — The  gonococcus  circulating  in  the  blood  is  the  exciting 
cause,  A\hile  knveretl  local  resistance  is  the  predisposing  factor  such 
as  is  found  in  fracture,  uifancy  and  the  like. 

Symptoms. — Added  to  the  symptoms  and  signs  of  the  original  gt)no- 
coccal  infection  and  the  secondary  septicemia  are  the  local  conditions 
of  the  abscess  Avhicli  Aary  with  the  situation.  In  literature,  ^Y.  Y. 
("ampbell'  details  a  compound  fracture  case  in  a  patient  with  a  six 
weeks'  gonococcal  infection,  followed  by  suppuration  of  the  fracture, 
due  to  the  gonococcus,  established  by  culture.  J.  Kerassotis^  has 
rejiorted  a  gonococcal  abscess  of  the  mastoid  regions,  secondary  to  a 
urethritis,  with  cure  of  both  conditions  together.  Y.  Meyer,^  before 
the  BerUn  ^Medical  Society,  presented  a  patient  with  superficial  right 
middle  felon  following  a  profuse  gonococcal  vaginitis.  The  same 
organisms  were  cultured  from  the  pus  of  the  felon.  Cassell,^  during 
the  discussion  of  F.  Meyer's  case  just  cited,  described  an  example  of 
gonococcal  ophthalmia  in  a  newborn  infant  with  early  secondary 
arthritis  and  dorsal  abscess  which  contained  a  pure  growth  of  the 
gonococcus.  Lang^  has  detailed  a  case  of  urethrocystitis  followed  by 
metastatic  abscesses  in  the  left  metacarpal  regions.  Klausner'''  and 
Reenstierna''  fully  establish  the  origin  of  their  cases,  Klausner  in  an 
abscess  of  the  bm^sa  over  the  tuberosity  of  the  tibia  and  Reenstierna 
one  in  the  left  upper  arm. 

Diagnosis.^ — A  mild  or  severe  septic  state  marks  the  history  of  an 
intense  extending  and  otherwise  complicated  gonococcal  urethritis  and 
shows  the  subjective  symptoms  of  the  sepsis  followed  by  or  accom- 
panied by  those  of  the  abscess,  respectively,  such  as  chills  or  chilliness, 
fever,  digestive  disorder,  circulatory  disturbance,  prostration  and  the 
like,  along  with  one  or  more  deposits  of  the  pus  at  almost  any  point 
accessible  to  examination,  which  verifies  all  the  foregoing  syndrome 
and  adds  recovery  of  pus  by  aspiration  or  incision.  In  the  laboratory 
such  a  specimen  must  deliver  the  gonococcus  for  smear  and  culture, 
alone  or  associated  with  the  pyogenic  organisms  and  the  blood  may 
be  in  a  state  of  bacteremia  and  positive  complement  fixation  test. 
Treatment  of  the  original  focus  of  disease  limits  fiuther  extension  of 
the  sepsis  and  thereby  the  origin  of  other  abscesses.  Suitable  support 
against  the  septic  process  itself  is  of  value  and  finally  incision  and 
drainage  of  the  abscess  prove  its  identity  and  secure  the  specimens 
for  the  final  demonstration. 

Treatment. — Abscess  itself  is  commonly  easy  to  treat  but  the  under- 
lying absorption  is  diflficult.  The  prophylaxis  is  the  same  as  the  under- 
lying bacteremia  and  toxemia  in  the  care  of  all  gonococcal  infection, 
especially  severe  cases  and  complications.  Abortion  of  the  cause  of 
the  abscesses  is  impossible  but  of  the  abscesses  themselves  consists 

1  New  York  Med.  Joui.,  February  28,  1908. 

'  Add.  d.  mal.  d.  org.  genito-urinaries,  1904,  xxii,  516. 

'  Deutsch.  Died.  Wchnschr.,  1903,  xxix,  Society  Proceedings,  p.  226.  ■*  Ibid. 

=•  Jahrb.  d.  Wien.  K.  K.  Krankenanstalten,  1892,  1893,  i,  514. 

6  Dermatol.  Wchnschr.,  1915,  ix,  723. 

'  Arch.  f.  Derm.  u.  Syph.,  1914,  exx,  870. 


GONOCOCCAL  METASTATfC  ABSCESS  237 

in  the  liberal  painting  of  the  affected  skin  with  tincture  of  iorlin  or 
95  per  cent,  carbolic  acid  until  white  coagulation  slightly  appears 
followed  and  combined  with  a  95  per  cent,  ethyl  alcohol  wet  dressing 
or  a  wet  dressing  of  1  in  5000  bichloride  of  mercury  or  0  per  cent, 
aluminum  acetate. 

Full  explanation  of  management  is  found  in  Chapter  IX,  on  General 
Principles  of  Treatment,  on  page  4S3. 

Physical  means  depend  on  cessation  of  the  pus-producing  process 
when  resorption  may  be  stimulated  by  judicious  massage  and  the 
application  of  the  Bier  hyperemic  treatment.  The  latter  may  be 
applied  even  earlier  to  stimulate  discharge  of  pus  and  destruction  of 
the  organism.  Massage  is  an  early  substitute  for  physical  exercise. 
Hydrotherapy  in  cold  often  reduces  pain  and  congestion  in  the  abortive 
attempt  and  in  heat  promotes  pointing  of  the  abscess  and  light  through 
its  heat  and  actinic  power — an  admirable  adjuvant,  as  is  also  electro- 
therapy when  tissue  massage  is  advisable,  but  only  after  drainage 
has  been  well  established.  The  static  brush  discharge  as  already 
described  under  Phlebitis  is  the  modality  of  most  service. 

The  medicinal  measures  during  the  acute  periods  avail  hardly  more 
than  in  septicemia  and  there  is  special  danger  in  serumtherapy  which 
may  be  fatal  through  increase  of  the  infection  during  the  negative 
phase.  All  the  treatments  detailed  for  the  convalescent  of  septicemia 
apply  here. 

The  surgical  measures  are  both  operative  and  nonoperative  and 
wet  dressings  and  applications  comprise  the  nonoperative  means  as 
mentioned  under  abortion.  Operation  consists  in  a  deep  linear  or 
crucial  incision  into  the  cavity  of  each  abscess  enlarged  with  scissors 
to  prevent  any  overhang  of  flaps  so  that  the  incisions  are  coextensive 
with  the  cavity.  Swabbing  each  abscess  with  tincture  of  iodin  or 
with  95  per  cent,  carbolic  acid  followed  by  95  per  cent,  ethyl  alcohol 
and  then  packing  it  with  gauze  followed  by  suitable  dressing  closes 
the  operation.    No  sutures  are  ever  used. 

Aftertreatment. — ^The  drains  are  left  as  long  as  there  is  discharge, 
decreasing  them  with  filling  of  the  wound  and  changing  them  to 
stimulating  dressings,  such  as  balsam  of  Peru,  and  associating  them 
with  applications,  such  as  10  per  cent,  silver  nitrate  solution,  also  for 
stimulation.  All  the  medicinal  means  suggested  in  the  aftertreatment 
of  septicemia  essentially  apply. 

Cure  pathologically  follows  the  same  rule  as  in  the  provocative 
blood  condition  and  sjonptomatically  the  abscess  must  be  healed 
without  sinus  and  only  a  node  of  the  abscess,  infiltration  and  the 
scar  of  the  incisions  left  for  slow  resorption. 

Arthritis. — In  a  certain  sense  arthritis  might  be  regarded  as  a  circu- 
latory complication,  but  it  is  discussed  as  a  separate  subject  on 
page  248. 

4.  Respiratory  Complications. 

Varieties.- — The  gonococcus  occurs  in  rhinitis  and  pleuritis. 


23S     COMPLICATIOXS  AXD  SEQIIU.S  OF  AVVTE   URETHRITIS 

GONOCOCCAL  RHINITIS. 

Significance.  Tlu-  I'vcs  iimst  Itr  ])r()t('ct('(l  against  I'xtcnsion  and 
(lirrct  iiioeulaTion. 

Occurrence.^  Tlio  nose  is  raivly  infrctod.  The  ^ouococciis  must  be 
(listiiiuuishcd  from  tlio  Micrococcus  catarrhalis  and  the  ^Micrococcus 
meningitidis  common  in  the  nose. 

Pathology. — The  lesions  are  the  same  as  those  of  any  othei-  mucosa 
(hn-ing  uonococcal  activities. 

Symptoms.— In  infants  and  adults  are  seen  chielly  purulent  discharge, 
pain,  nasal  dyspnea,  edema,  obstruction  and  all  other  e\idence  of 
severe  rhinitis. 

Diagnosis.- — The  essentials  are  proof  of  the  source  of  the  infection, 
the  tyi)ical  syndrome  and  the  gonococci. 

Treatment. — Prophylaxis  resides  in  care  of  the  m'ethritis.  llhinitis 
always  suggests  accepted  management,  medication  and  a])])lications 
to  destroy  the  gonococcus  and  to  restore  the  mucosa. 

GONOCOCCAL  PLEURITIS. 

Significance  and  Occurrence.- — The  origin  in  ahvays  septic  during 
bacteremia  and  the  proof  is  usually  on  autopsy,  luarking  the  rarity 
of  gonococcal  plem-itis. 

Etiology. — Growth  of  the  gonococcus  on  the  plein-a  and  in  its  cavity 
follo^^'s  bacteremia  from  an  active  focus  elsewhere. 

Pathology. — The  gonococcus  is  \'irtually  the  only  dift^'erence  between 
this  and  other  purulent  pleuritis* 

Symptoms. — Pleurisy  without  efTusion  is  early  and  later  with  effusion, 
each  ^\■ith  its  usual  characteristics — all  associated  with  the  symptoms 
of  the  gonococcal  focus. 

Diagnosis. — The  precedent  septic  gonococcal  process  must  be  defined 
together  with  the  usual  s^aidrome  of  pleurites  and  the  gonococcus  in 
the  exudate. 

Treatment. — ^The  gonococci  and  their  lesions  must  be  removed  from 
their  original  site  while  the  pleurisy  is  being  managed  along  well- 
accepted  principles. 

5.  Nervous  Com  plications. 

Significance,  Occurrence  and  Varieties. — Nervous  complications  indi- 
cate ])rofound  absorption.  They  occur  only  during  bacteremia  and 
septicemia,  accompanied  by  lesions  in  other  organs.  Acute  forms 
])re(l()niiiiate.    The  foci  arc  cerebral,  spinal,  meningeal  and  peripheral. 

Etiology. — The  gonococcus,  with  its  toxins,  is  absorbed. 

Diagnosis. — A  primary  focus  of  the  gonococcus  in  a  septic  case  is 
essential.  The  typical  cerebral  syndrome  and  the  organisms  in  the 
blood  are  final. 

A.  Central  Nervous  Complications. 

Varieties. — Of  cerebral,  spinal  and  nieiiingeal  forms,  the  cerebral  is 
the  least  common. 


GONOCOCCAL  MENINGITIS  239 

GONOCOCCAL  CEREBRITIS. 

Occurrence. — Obscure  and  rare  reports  often  lack  })actcri()lof,n'c"tl 
proof. 

Symptoms. — Delirium,  mania,  meningitis  and  apoplexy  have;  })e(;ii 
described  according  to  the  brain  elements  involved. 

Diagnosis. — The  essentials  of  proof  are  the  lesions  of  origin,  bacterio- 
logically  established,  and  the  cerebral  sequels. 

Treatment. — The  primary  gonococcal  foci  belong  to  the  uroUjgist  and 
the  cerebral  lesions  to  the  neurologist. 

GONOCOCCAL  MYELITIS. 

Occurrence. — The  cord  is  more  often  involved  than  the  brain. 

Etiology. — Intoxication  of  the  myelon  with  the  bacteria  and  toxins 
is  the  cause. 

Pathology. — Disseminated  or  segmentary  myelitis  as  suppurative 
inflammation  followed  by  subsidence  or  destruction  of  the  nerves, 
cells  and  fibers  is  present.  Secondary  muscular,  sensory,  trophic  and 
reflex  nerve  changes  are  seen. 

Symptoms. — The  characteristic  stages  of  onset  and  irritation  followed 
by  subsidence  or  by  paresis  or  paralysis  of  muscular,  sensory,  trophic 
or  reflex  function  are  seen. 

Diagnosis. — The  gonococcus .  must  be  an  element  in  the  myelitis. 
In  difterentiation  the  primary  seat  of  the  disease  is  important. 

Treatment. — The  myelitis  must  be  referred  to  a  nerve  specialist 
while  a  urologist  cures  the  original  focus. 

GONOCOCCAL  MENINGITIS. 

Varieties.^ — Cerebral,  spinal  and  cerebrospinal  are  distinguished. 

Etiology. — The  meninges  are  attached  by  gonococci  circulating  in 
the  blood. 

Pathology. — All  the  recognized  lesions  of  suppurative  meningitis 
are  present  through  the  activities  of  the  gonococcus. 

Symptoms. — A  severe  gonococcal  infection  is  followed  by  septic 
signs  and  then  by  nervous  irritation  and  depression. 

Diagnosis. — The  source  of  the  gonococcal  absorption  and  sepsis 
must  be  proved,  then  follows  the  syndrome  of  cerebral  or  spinal 
meningitis  or  both.    Autopsy  alone  gives  the  final  proof. 

Treatment. — The  nervous  infection  belongs  to  the  general  medical 
or  neurological  expert.  The  vaginal  focus  must  be  treated  by  the 
urologist. 

B.  Peripheral  Nervous  Complications. 

Occurrence. — Obvious  intoxication  from  chronic  foci  foreruns  these 
lesions. 

Varieties. — Neuralgia,  neuritis  and  neuroses  are  the  common  forms. 


240     COMPLICAriOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

GONOCOCCAL  NEURALGIA,  NEURITIS  AND  NEUROSES. 

Etiology. — Obscure  chronic  abst)i-})tic)u  is  the  chief  factor. 

Pathology. — The  lesions  are  functional  rather  than  organic,  so  that 
true  pathology  may  he  absent.  The  nerves  attacked  are  musculo- 
cutaneous, radial,  median,  tibial,  sciatic,  lumbosacral,  lumbo- 
abdominal  and  intercostal. 

Symptoms. — \'arious  and  typical  signs  of  each  are  fully  described  in 
works  on  neurology.  Neuralgia  predominates  in  pain  and  sensitiveness. 
Neuritis  may  show  sensory,  trophic,  reflex  and  muscular  changes. 
Neurosis  is  highly  various. 

Diagnosis. — Definite  decision  is  difficult.  Ivelief  of  the  s^nnptoms 
by  cure  of  the  gonococcal  focus  is  important. 

Differential  Diagnosis. — The  nem'ites  of  poisoning  (chiefly  metallic) 
infections,  rhemnatism,  gout  and  wasting  disease  must  be  distinguished. 

Treatment. — The  original  point  of  absorption  must  be  cured  by  the 
urologist,  otherwise  the  greatest  skill  of  the  neurologist  will  fail. 

6.  Ocular  Complications. 

Significance.^ — The  eye  is  a  peripheral  nerve  organ  which  determines 
the  classification  of  gonococcal  infection  of  it. 

Varieties. — Exogenous,  proceeding  from  without  the  eye,  and  endoge- 
nous or  metastatic,  transferred  by  the  blood  current,  are  the  two 
forms. 

Etiology. — Direct  transfer  of  the  virus  may  arise  through  instru- 
ments and  the  fingers  of  attendants  upon  children  and  the  sick.  A 
primary  gonococcal  focus  is  the  source  of  metastases. 

GONOCOCCAL  IRITIS  AND  CHOROIDITIS. 

Significance  and  Occurrence.— Profound  eye  lesions  always  mean 
gonococcal  septicemia.  The  iris,  choroid  and  optic  i^rve  may  be 
individually  or  collectively  affected. 

Varieties.- — Primary  and  secondary  forms  are  usual.  Primary  lesions 
represent  deposits  before  a  true  septicemia  is  established.  Acute 
courses  only  are  seen. 

Etiology. — Septic  metastasis  causes  the  endogenous  form  and  direct 
transfer  of  pus  the  exogenous  form. 

Pathology. — In  iritis  there  are  congestions,  swelling,  infiltration  and 
exudation  of  serimi  blood  and  pus,  forming  hypopyon.  Choroiditis 
shows  infiltration  of  the  choroid  and  outer  layers  of  the  retina. 

Symptoms. — Full  discussion  must  be  referred  to  works  on  diseases  of 
the  eye  to  which  nuist  be  added  the  gonococcal  focus  and  septicemia. 

Diagnosis. — An  eye  specialist  should  be  called  for  each  case.  Demon- 
stration of  the  primary  lesion  and  the  absorption  is  easy. 

Treatment. — The  source  of  the  gonococcus  must  be  cured  for  correc- 
tion of  the  septic  state  while  the  eye  must  remain  under  the  care  of  an 
ophthalmologist. 


GONOCOCCAL  CONJUNCTIVITIS  241 

Electrotherapy  is  peculiarly  serviceable.  The  positive  pole  of  a  high- 
speed, multiple-plate  static  machine  is  grounded,  and  the  negative  pole 
is  connected  with  a  specially  shaped,  high-potential  vacuum  eye  elec- 
trode. The  spark-gap  is  a  half-inch.  The  strength  of  current  is  one 
milliampere,  the  duration  is  for  twenty  minutes  at  each  sitting,  and 
the  repetition  for  treatment  is  at  first  twice  daily  and  then  at  longer 
intervals,  according  to  improvement.  The  results  are  very  quick  relief 
of  pain  by  promotion  of  absorption  of  infiltration  and  exudation. 
There  are  no  afterresults  and  the  medication  of  the  eye  specialist  may 
be  applied  at  the  same  time. 

GONOCOCCAL  CONJUNCTIVITIS. 

Significance. — This  disease  has  very  great  importance  in  children  and 
adults  owing  to  acute  destruction  of  the  eye  unless  proper  treatment  is 
instituted  and  followed  from  the  outset.  In  any  event  a  certain  degree 
of  damage  is  assured.  The  services  of  an  ophthalmologist  should  be 
secured  as  soon  as  the  diagnosis  is  settled. 

Occurrence. — Before  the  work  of  Crede,  in  1881,  conjunctivitis  in  the 
newborn  was  very  common.  It  may  be  safely  said  that  practically 
all  blindness  following  conjunctivitis  immediately  after  childbirth  was 
due  to  this  one  cause.  Likewise  before  the  age  of  bacteriology,  gono- 
coccal conjunctivitis  in  older  children  from  error  in  asepsis  in  institu- 
tions and  homes,  and  in  adult  patients  themselves  from  carelessness, 
was  also  a  very  common  disease.  Relatively  speaking,  it  is  now 
uncommon,  wherever  ordinary  intelligence  may  be  enlisted,  both  in 
the  care  of  the  eyes  of  the  newborn,  of  utensils  in  institutions  and  of  the 
hands  of  adult  patients.  The  disease  is  more  frequent  in  the  homes  of 
the  poor  than  in  institutions,  owing  to  the  frequency  of  uncured  gono- 
coccal lesions  in  that  class,  and  their  inability  and  ignorance  in  provid- 
ing the  means  and  carrying  out  the  method  of  prevention  and  cure. 

Etiology. — The  gonococcus  of  Neisser  is  regularly  the  exciting  agent, 
while  the  avenue  of  invasion  or  predisposing  cause  is  in  the  newborn 
vulvovaginitis  in  the  mother,  whose  discharge  directly  contaminates 
the  eyelids  of  the  baby.  The  onset  is  always  within  forty-eight  or 
seventy-two  hours,  in  postpartum  cases.  Long  dry  labor  with  its 
attendant  traimiatism,  the  lack  of  resistant  epithelimn  and  the  absence 
of  tear  glands  in  the  eye  of  the  newborn,  ^re  all  predisposing  causes. 
All  forms  of  urogenital  discharge  at  any  age  and  in  both  sexes  should 
be  regarded  as  sources  of  serious  danger.  It  is  in  the  declining  stage 
of  gonococcal  disease  in  the  adult  when  suffering  is  over  and  careless- 
ness invited  that  infection  occurs. 

Antepartum  or  congenital  cases  due  to  progress  of  the  gonococcus 
into  the  uterus  usually  after  ruptm-e  of  the  membrane  before  birth 
have  been  reported.  Incubation  longer  than  foiu"  or  five  days  is  apt 
to  indicate  accidental  infection  after  birth,  such  as  from  linen,  of  the 
mother  or  other  children,  failure  of  asepsis  in  the  institution  and  the 
like. 

16 


242     COMPLICATIONS  AND  SEQUELS  OF  ACUTE   URETHRITIS 

In  older  children  and  in  adults,  the  transfer  of  the  organism  to  the 
eye  is  either  through  Aarioiis  utensils  or  infected  fingers  of  attendants 
or  the  ]iatients  themselves.  Nurses  may  readily  have  such  fingers  from 
the  insertion  of  thermometers  into  the  rectums  of  uifected  children, 
particularly  females. 

It  is  well  to  enumerate  the  other  organisms  of  purulent  conjunctivitis 
especially  in  young  infants  which,  by  this  term,  may  be  distinguished 
from  gonococcal  conjunctivitis.  Among  the  cocci  are  i)neumococcus, 
streptococcus  and  other  pyococci,  ^Micrococcus  luteus  and  Micro- 
coccus catarrhalis.  Among  the  bacilli  are  those  of  Koch-Weeks, 
Klebs-Loefl!er  of  diphtheria,  bacillus  of  ]\Iorax-Axenfeld,  ])neumo- 
bacillus,  true  and  false  bacillus  of  influenza,  streptobacillus  and  Bacillus 
pyocyaneus.  This  large  variety  proves  the  need  of  most  careful 
bacteriological  research  in  suspected  cases  before  conclusions. 

Pathology. — As  in  all  other  mucous  membranes  the  gonococcus  in 
the  conjunctiva  produces  the  typical  changes  in  series,  congestion, 
exfoliation,  infiltration,  suppuration,  ulceration  and  the  like.  The 
great  delicacy  of  the  membrane  in  the  newborn  and  even  in  the  adult 
makes  the  entire  process  even  more  severe  than  in  the  lu-ethra.  Thus 
temporary  lesions  are  comparatively  rare,  and  do  not  occur  unless 
ulceration  is  avoided  by  efficient  treatment.  The  permanent  lesions, 
on  the  contrary,  are  chiefly  the  complications  and  sequels  which 
Pechin^  enumerates  as  infection  of  the  cornea  possibly  leading  to  ulcer- 
ation, perforation,  retrochoroidal  hemorrhage,  lesions  of  the  iris,  sec- 
ondary glaucoma,  leucoma,  staphyloma,  panophthalmia  and  anterior 
polar  cataract.  Thus  the  possibilities  are  extremely  severe.  Ulcera- 
tion and  cicatrization  of  the  cornea  lead  to  blindness. 

Symptoms. — The  disease  manifests  itself  slightly  differently  in 
infants,  adults  and  the  aged,  being  much  more  severe  in  the  first  and 
the  last  owing  to  lowered  resistance  at  the  extremes  of  life.  Periods 
of  invasion,  establishment  and  termination  may  be  recognized  each 
with  its  local  and  systemic  subjective  and  objective  sjTnptoms.  Chil- 
dren cannot  always  describe  their  condition  which  is  necessarily  often 
only  objective.  The  period  of  invasion  is  shown  in  infants  by  dashes 
or  spots  of  redness  in  the  conjunctiva  of  the  lids.  In  adults  the  sub- 
jective local  sjTuptoms  are  tickling  as  of  foreign  body,  hyperemia  and 
tendency  to  rub  the  eye,  then  lachrymation  followed  by  a  serous  or 
mucoserous  discharge  with  gonococci  and  with  slight  thickening  so  as 
to  gum  the  lashes.  The  objective  local  symptoms  are  at  first  on  the 
palpebral,  then  on  the  bulbar  conjunctiva  great  redness  and  edema,  so 
that  the  latter  is  even  elevated  above  the  cornea  which  seems  to  lie 
in  a  depression  and  later  shows  its  bloodvessels  prominently.  Exfoli- 
ation of  the  mucosa  is  shown  by  roughness.  In  the  subjective  estab- 
lishment the  tickling  changes  to  pain,  heat  and  tension,  radiating  to 
the  eyebrow,  temple  and  forehead.  Photophobia  is  an  early  and  pro- 
gressive sjinptom.    The  objective  local  signs  are  that  the  watery 

1  Pechin,  Luys:  Loc.  cit.,  p.  243. 


GONOCOCCAL  CONJUNCTIVITIS 


243 


becomes  a  purulent  discharge  loaded  with  gonococci.  The  redness, 
roughness  and  edema  become  extreme  so  that  it  is  difficult  to  open  the 
eye,  except  with  elevators  and  so  that,  at  times,  the  upper  overlies 


•\. 


Fig.  56. — Ophthalmia  neonatorum.     (After  Haab.) 


Fig,  57. — Total  blindness  due  to  perforation  of  the  eyeball  and  escape  of  its 
fluid  contents.    (De  For  est. i) 

the  under  lid  and  may  be  more  or  less  everted.    The  systemic  symp- 
toms are  in  all  ages  a  febrile  movement,  rapid  irritable  pulse,  anxious, 


1  De  Forest:  New  York  Med.  Jour.,  May  29,  and  June  5,  1915. 


244     COMPLICATIONS  AND  SEQUELS  OF  ACUTE   URETHRITIS 

nervous  and  tense  state.  The  untreated  disease  is  apt  to  run  an  acute 
severe  ratlier  than  a  subacute  mild  course.  Only  the  most  prompt 
efficient  treatment  giA'es  hope  of  good  result. 

The  termination  is  favorable  only  when  treatment  is  extremely 
prompt,  efficient  and  ]>roperly  applied.  Fatalities  do  not  occur, 
although  Polit/.er'  describes  a  case  in  which  i)urulent  conjunctivitis 
was  followed  by  meningitis,  buj;  it  cannot  be  stated  bacteriologically 
whether  this  infection  was  gonococcal  or  not.  The  report  is,  however, 
highly  suggestive  of  possibilities.  In  modern  days  full  recovery  is 
more  and  more  connnon,  owing  to  early  diagnosis  and  modern  anti- 
septics, but  e^'en  with  these  ad\'antages  the  early  involvement  of  the 
epithelium  over  the  cornea  commonly  leads  to  more  or  less  ulceration 
and  later  scar  and  defective  vision.  In  extreme  cases  deformity  of 
tlie  eyelids  themselves  is  seen  and  total  destruction  of  the  eye  as  an 
Oi'gan. 

Severe  cases  in  a  few  hours,  o\'ernight  or  in  a  day,  may  result  in 
total  destruction  of  the  eye.  Bilateral  cases  are  somewhat  more 
severe  than  unilateral,  possibly  due  to  the  greater  difficulty  of  suitable 
attention  to  both  eyes.  In  the  extremes  of  life,  infancy  and  age,  the 
bodily  powers  are  deficient  and  tlie  disease  is  more  destructive. 

Complications. — Complications  are  rare  and  belong  to  the  class  of 
absorption,  such  as  arthritis.  The  preauricular  lymphatic  gland  is 
often  involved,  as  it  drains  the  conjunctiva. 

Diagnosis. — Any  ophthalmia  arising  at  or  immediately  after  child- 
birtli  in  the  infant,  or  during  any  period  of  gonococcal  infection  in  the 
adult  demands  the  most  careful  bacteriological  investigation,  even 
in  the  stage  before  pus  is  developed,  which  is  the  moment  of  accom- 
plishing the  best  early  control  of  the  case.  Distinction  between 
gonococcal  conjuncti\'itis  and  purulent  conjunctivitis,  which  is  excited 
by  the  organisms  given  under  the  heading  of  etiology,  is  very  neces- 
sary. The  writer  had  a  case  of  simple  pink-eye  appear  during  a 
gonococcal  urethritis,  ha^'ing  all  the  early  features  of  a  gonococcal 
conjuncti^•itis.  The  patient  was  immediately  referred  to  an  eye  clinic 
where  the  full  diagnosis  and  treatment  were  immediately  given.  Such 
cases  are  by  no  means  uncommon  and  early  neglect  leads  to  serious 
results.  The  history,  therefore,  uncovers  the  incidence  of  the  con- 
jimctivitis  directly  after  chil(ll)irth  by  a  mother  suffering  from  leiicor- 
rhea  or  even  without  known  lesion,  or  its  occurrence  during  a  gonococcal 
urethritis  in  the  child  or  adidt  with  people  who  are  not  cleanly  in  the 
instincts  or  its  mediate  origin  from  the  fingers  and  utensils  of  nurses 
and  other  attendants  of  children  who  have  disregarded  asepsis.  Sub- 
jective s.Miiptoms  are  absent  in  young  children,  but  older  ones  and 
adults  ma>'  describe  the  rapidly  progressing  irritation,  watery  lachry- 
mation  followed  by  pus,  pain  and  increasing  photophobia.  The  objec- 
tive symptoms  are  those  of  early,  fiery  redness,  edema  and  exfoliation 
of  the  epithelium  and  pus  containing  the  gonococcus  with  or  without 

'  Jahrb.  f.  Kinderheilk.,  1870,  p.  335. 


GONOCOCCAL  CONJUNCTIVITIS 


245 


other  organisms.  The  laboratory  findings  prove  the  })acteriological 
cause  and  should  always  be  carried  out  immediately,  as  delay  in  the 
distinction  of  the  disease  may  be  costly  to  the  jjatient.  'iVeatment 
is  not  of  great  value  in  the  diagnosis  except  that  the  resistance  of  the 
gonococcus  to  ordinary  means  only  corroborates  the  clinical  and 
bacteriological  evidence.  Metastatic  gonococcal  conjunctivitis  must 
always  be  borne  in  mind,  and  is  suggested  chiefly  by  the  presence  of 
other  foci  of  infection  in  other  parts  of  the  bod\',  especially  perhaps 
arthritis. 


Fig.  58. — Gonococcal  ophthalmia  in  the  adult,  showing  great  congestion  of  the 
conjunctiva,  pericorneaJ  injections,  free  purulent  discharge.     (Taylor.^) 

Differential  Diagnosis. — Purulent  conjunctivitis  may  arise  from  a 
number  of  infections  other  than  gonococcal,  as  indicated  in  the 
paragraph  on  etiology.  The  list  of  organisms  thus  present  may  be 
repeated.  Among  the  cocci  are  pneumococcus,  streptococcus  and 
other  pyococci,  Micrococcus  luteus  and  ^Micrococcus  catarrhalis. 
Among  the  bacilli  are  those  of  Koch- Weeks,  Klebs-LoefHer  of  diphtheria, 
Morax-Axenfeld,  pnemnobacillus,  true  and  false  bacillus  of  influenza, 
streptobacillus  and  Bacillus  pyocyaneus.  This  large  variety  proves 
the  need  of  most  careful  bacteriological  research  in  suspected  cases 
before  conclusions.  It  is  manifest  that  a  mucous  sac  as  small  as  the 
conjunctiva  and  an  organ  as  sensitive  as  the  eye  can  both  react  to 
any  infection  in  practically  the  same  series  of  symptoms  in  kind  but 


1  Loc.  cit. 


240     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE  URETHRITIS 

(lilVering  in  derive.  Thus  from  the  coujunctha  \vc  hjive  redness, 
s^velHn^.  exfoHatioii,  discliar^e,  discomfort,  pain,  and  from  tlie  eye, 
irritation  and  photo])hobia,  which  are  mild  in  the  catarrhal  and  marked 
in  the  sni)])uratiNe  infections.  Symi)toms  (tf  destruction  of  the  eye 
are  omitted  because  this  is  a  terminal  secjuel  and  the  dill'erential  diag- 
nosis must  be  made  preferably  durinj]^  the  incubation  and  certainly 
early  in  the  invasion.  Careful  bacteriology  alone  will  distinguish  all 
the  foregoing  bacteriological  causes  from  each  other  and  from  the 
gonococcus. 

Treatment. — Promptness,  consistency  and  joersistency  of  treatment 
are  the  keys  of  the  problem.  Prophylaxis  at  childbirth  consists  in 
the  method  of  Crede,  by  which  the  eyelids  of  the  newborn  child  are 
washed  with  boric  water  and  then  1  to  2  drops  of  2  ])er  cent,  nitrate 
of  silver  solution  are  instillated  upon  the  conjunctiva,  l^eaction  is 
controlled  with  normal  salt  or  boric  acid  solution.  If  the  infection 
appears,  the  hands  of  the  child  had  best  be  restrained  from  rubbing 
the  eyes,  especially  when  only  one  is  involved,  and  in  adults  the  miin- 
fected  eye  is  protected  with  a  shiekl  made  either  of  a  ])iece  of  celluloid 
cut  to  tit  brow,  nose  and  cheek  or  a  watch-glass  of  suitable  size.  Either 
is  placed  o^'er  the  eye  and  secured  on  all  sides  with  adhesive  plaster 
of  which  the  edges  are  fastened  with  flexible  collodion.  All  dressings 
should  be  burned  and  attendants  warned  to  keep  their  own  hands 
scrupidously  clean  and  to  wear  goggles  to  protect  their  own  e>'es. 

Abortion  of  the  infection  is  possible,  if  diagnosed  very  early,  by 
irrigation  with  warm  boric  acid  solution  followed  by  the  instillation 
of  the  silver  nitrate  solution  twice  a  day  and  the  use  of  25  or  50  per  cent, 
argyroj  solution  between  times.  Such  measures  should  be  continued 
several  days  associated  with  frequent  examination  of  smears  until  tiie 
gonococcus  is  no  longer  present.  If  pus  has  already  developed  these 
measures  will  fail  and  may  succeed  only  in  the  serous  and  mucous 
stages  exactly  as  in  urethritis. 

General  Treatment  in  Chapter  IX  contains  all  details  of  management 
on  page  4S3. 

Curative  Treatment. — All  measures  must  be  promptly  adopted  and 
consistently  followed. 

^Medicinal  measures  in  the  acute  stage  are  by  local  administration, 
irrigations  and  washings  of  the  conjunctival  sac  with  cold  boric  acid 
or  normal  salt  solution  follow^ed  by  the  instillation  of  antiseptics. 
All  exudate  must  be  washed  away  as  rapidly  as  it  occurs  and  the  2 
per  cent,  nitrate  of  silver  solution  should  })e  employed  night  and 
morning  and  the  arg\Tol  solution  at  frequent  intervals,  with  care  not 
to  induce  a  chemical  irritation  by  either. 

Physical  measures  recognize  chiefly  hydrotherapy  in  the  irrigation 
of  the  conjunctiva  sac  with  normal  salt  solution  or  boric  acid  water  to 
remove  the  exudate,  followed  by  the  instillation  of  the  antiseptic  drops 
such  as  2  per  cent,  nitrate  of  silver  twice  a  day  associated  with  argyrol 
10  to  50  per  cent,  and  in  cold  applications  with  small  pieces  of  cotton 
or  gauze  fitting  the  eyeball  and  passed  directly  from  a  cake  of  ice. 


aONOCOCCAL  CONJUNCT  IV  IT  J  ^  247 

Such  pads  should  never  be  used  a  second  time,  so  that  a  great  number 
of  them  should  be  prepared.  The  heliotherapy  a])])]ied  to  the  aff(;eted 
temple,  side  of  the  head  and  neck  is  a  valid  and  active  deconf^cjstant 
and  may  be  used  many  times  daily  for  long  periods  until  the  skin  is 
quite  red.  Its  decongesting  and  soothing  action  equals  that  of  blood- 
letting with  leeches  at  the  temple.  'J'he  eyelashes  are  kept  free  of  pus 
by  gentle  mopping.  If  the  cornea  becomes  involved,  iritis  is  often 
prevented  and  always  benefited  by  instillating  1  per  cent,  atropin 
solution  to  keep  the  pupil  dilated,  at  rest  and  without  adhesions.  The 
silver  nitrate  is  stopped  at  the  same  time.  Ulcerations  of  the  cornea, 
synechise  and  deformity  of  the  lids  resulting  from  this  disease  are  fully 
discussed  in  works  on  ophthalmology. 

The  surgical  measures  are  nonoperative  and  operative.  The  non- 
operative  steps  are  blood-letting  with  leeches,  for  which  heliotherapy 
may  well  be  substituted.  The  operative  technic  is  multiple  puncture 
of  the  eyelids  for  extreme  edema  and  if  chemosis  with  its  dangers  of 
pressure  on  the  eyeball  and  cornea  appears,  the  tension  and  swelling 
are  relieved  by  dividing  the  ocular  and  palpebral  mucous  membranes 
with  blunt  scissors.  If  this  does  not  relieve  then  the  outer  canthus 
may  be  cut  to  give  free  access  to  all  the  cavities  and  recesses  of  the 
membrane.  Such  procedures  belong  to  the  specialists  in  diseases  of 
the  eye. 

Aftertreatment. — Immediate  aftertreatment  seeks  relief  of  the  chronic 
catarrh  following  the  certainty  of  destroyed  gonococci  and  respects 
possible  dangers  to  the  other  eye  for  a  definite  period  after  treat- 
ment is  stopped.  Relief  of  the  infection  in  the  urethra  is  a  definite 
element  in  the  aftercare.  Remote  aftertreatment  involves  appli- 
cations of  the  sulphate  of  zinc  or  copper  to  the  gramdar  eyelids,  Knapp's 
compression  operation  if  these  stimulations  fail,  various  operations 
on  the  cornea,  iris  and  eyelids  and  even  enucleation  and  perhaps  the 
wearing  of  a  glass  eye  in  cases  of  various  deformity  or  total  destruction, 
respectively.  These  procedures  belong  to  special  work  on  the  eye 
and  are  therefore  omitted. 

Cure,  pathologically,  aims  at  removal  of  the  infection  and  the  pre- 
vention of  profound  damage  but  often  fails  of  full  realization  on 
account  of  the  delicacy  of  the  eye  and  the  rapidity  of  the  process. 
Disappearance  of  the  gonococci  is  essential.  The  eye,  sjinptomatic- 
ally,  should  be  serviceable  or  even  normal  and  free  of  catarrh  or  defor- 
mity in  the  eyeball  or  lids,  and  bacteriologically  without  infecting 
organisms  such  as  the  gonococcus  or  its  allies. 

7.  Locomotory  Complications. 

Synonym. — Gonococcal  rheumatism  is  common,  but  is  nondescrip- 
tive  and  without  recognition  of  definite  lesions. 

Significance. — Gonococcal  synovial  complications  denote  systemic 
invasion.  The  gonococcus  and  its  toxins  have  selective  action  on  all 
synovial  membranes,  and  particularly  those  of  the  locomotory  system. 


24S     COMPLTCATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

Occurrence. — Locomotor  oom])lIcatioiis  are  the  most  common  extra- 
genital manifestations.  They  are  acute,  absorptive  or  chronic  relaps- 
ing in  tv'pe.  Joint,  tendon  sheath,  muscle,  biu-sa,  cartilage  and  peri- 
osteum may  be  invohed.  They  are  all  focal  signs  of  absor])tion  usually 
proceeding  from  posterior  urethral  infection  and  its  comjilications. 

Varieties. — According  to  the  tissue  attacked,  there  are  recognized 
arthritis,  tenosynovitis,  myositis,  bursitis,  chondritis,  perichondritis 
and  periostitis. 

GONOCOCCAL   TENOSYNOVITIS. 

Occurrence. — Tenosynovitis  is  less  common  than  arthritis.  Women 
(imless  pregnant)  suffer  less  than  men  and  children.  Neighboring 
joints  are  often  invohed.  The  affected  sheaths  are  those  of  peronei, 
manual  and  pedal  digital  extensors  and  flexors,  radial  extensors,  mus- 
cles of  the  thimib,  semitendinosus  and  semunembranosus. 

Varieties. — iVcute,  subacute  and  chronic  are  the  com-ses  of  serous 
and  suppurative  exudates. 

Etiology. — ^Metastatic  gonococcal  infection  is  ahvays  present. 

Symptoms. — Those  of  the  focus  of  absorption  and  of  severe  teno- 
synovitis are  the  picture. 

.    Diagonsis. — Relief  of  the  focus  often  proves  the  nature  of  the  com- 
plication. 

Treatment. — Recognized  surgical  care  of  the  infected  sheath  and  cure 
of  the  gonococcal  focus  are  the  elements. 

GONOCOCCAL   PERIOSTITIS,    PERIOSTOSIS,    MYOSITIS, 
BURSITIS,    CHONDRITIS   AND   PERICHONDRITIS. 

Occurrence  and  Etiology. — All  these  lesions  are  very  rare.  Their 
soiu"ce  is  regularly  a  genital  focus  of  acute  or  chronic  gonococcal  disease. 

Clinical  Features. — In  no  respect  except  early  severity,  followed  by 
chronicity  and  the  presence  of  the  focus  of  absorption,  do  the  gono- 
coccal forms  differ  from  other  types. 

Diagnosis. — Gonococcal  infection  and  absorption  must  be  proved. 
The  organism  may  occur  at  the  sites  of  complication. 

Treatment. — Cure  of  the  sexual  lesion  is  the  first  step.  The  other 
details  are  good  management,  protection,  hydrotherapy,  baking,  elec- 
trotherapy, heliotherapy,  Bier's  hyperemia  and  suitable  medications. 

GONOCOCCAL   ARTHRITIS. 

Occurrence. — Involvement  of  the  joints  is  the  most  frequent  loco- 
motory  and,  therefore,  extragenital  complication  of  gonococcal  disease. 
In  frequency  about  2  per  cent,  of  all  cases  suffer  from  it  and  a  much 
higher  percentage  in  the  complicated  cases,  especially  those  in  men 
with  seminal  vesiculitis  and  in  women  Avith  sali)ingitis.  It  commonly 
makes  its  appearance  during  the  first  or  second  week  of  severe  absorp- 


GONOCOCCAL  A  RTJIUTriH  249 

tive  acute  or  of  exacerbations  of  chronic  cases  and  their  coinjjlications. 
The  posterior  urethra  is  the  particular  starting-point.  'J'he  joints 
are  invaded  in  descending  frequency  as  follows:  K'nee,  ankle,  wrist, 
fingers,  toes,  shoulder,  hip  and  teinporoin axillary.  'J'he  same  joints 
on  both  sides,  or  various  joints  on  one  side  or  different  sides  of  the 
body  may  be  invaded. 


Fig.  59. — ^Author's  case  of  short  streptococcus  arthritis  of  the  elbow.  About  eight 
years  after  infection  arthritis- developed  in  one  ankle  and  the  small  joints  of  the  hand 
in  addition  to  both  elbows.  The  ankle  is  shown  in  Fig.  60.  About  25  per  cent,  lim- 
itation of  motion  was  present.  The  .T-ray  picture  shows  the  thickening  and  deposits 
in  the  synovise.  Careful  bacteriologic  search  revealed  the  streptococcus  and  not  the 
gonococcus  and  the  focus  of  absorption  was  in  the  seminal  vesicles  and  prostate,  but 
the  wife  of  the  patient  seemed  to  have  escaped  any  infection. 

Varieties. — Acute  and  subacute,  progressive  chronic  and  relapsing 
chronic  are  the  clinical  forms  as  to  course,  while  those  as  to  site  of  the 
lesion  are  arthrosynovitis,  arthritis  and  osteoarthritis,  in  which 
respectively  the  synovia  alone,  the  joint  as  a  whole  and  the  joint  with 
the  bone  surfaces  and  cartilages  are  involved. 

Etiology. — Arthritis  is  never  primary  but  always  secondary  to 
gonococcal  conditions  elsewhere,  which  in  the  uretlira  is  anterior 
occasionally,  but  posterior  usually,  either  acute  or  chronic,  especially 
of  the  relapsing  and  complicated  forms.  The  predisposing  factors 
are  age  and  sex,  which  are  of  little  importance  although  males  suffer 
more  frequently  than  females.  Heredity,  predisposition  to  articular 
lesions  and  little  resistance  to  absorptive  effects  of  any  infection  are 
important.  Lessened  articular  resistance  tlu'ough  previous  attacks 
of  other  forms  of  rhemnatism,  gout,  injmy,  exposiu'e,  exertion,  and 


250     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

occupation  Avliicli  leads  to  overuse  of  certain  members  are  elements  of 
influence.  The  writer  had  a  case  of  gonococcal  arthritis  of  the  hand 
in  a  je\velry-])olisher,  whose  finu;ers  were  necessarily  almost  always 
overused.  rre\"ious  attacks  of  gonococcal  arthritis  are  the  most 
potent  predisposition.  The  excitinij  cause  is  regularly  the  gonococcus 
and  its  toxins,  alone  or  associated  with  other  pyogenic  organisms, 
deposited  and  developing  in  the  joint  and  its  structures.  The  source 
of  the  organisms,  as  already  stated,  is  commonly  a  posterior  urethritis, 
rarely  acute  but  usiuilly  rclajising  or  chronic  with  com])lications.     Of 


Fig.  60. — Author's  rase  of  short  streptococcus  arthritis  of  the  aukie.  About  eight 
years  after  infection  arthritis  developed  in  both  elbows  and  the  small  joints  of  one 
hand  in  addition  to  the  ankle.  One  elbow  is  shown  in  Fig.  59.  About  25  per  cent, 
limitation  of  motion  was  present.  The  x-ray  picture  shows  the  thickening  and 
deposits  in  the  synoviae.  Careful  bacteriologic  search  revealed  the  short  streptococcus 
and  not  the  gonococcus  and  the  focus  of  absorption  was  in  the  seminal  vesicles  and 
prostate,  but  the  wife  of  the  patient  seemed  to  have  escaped  any  infection. 


the  last  in  males  the  most  fertile  is  seminal  vesiculitis,  probably  due  to 
the  small  size,  functional  activity,  vascular  complicated  mucosa,  readily 
occluded  outlet  and  actively  absorbing  surface.  For  duplicate  reasons 
in  females  the  tube  is  the  chief  source  of  joint  conditions. 

Cases  in  which  the  gonococcal  infection  is  pure  and  those  in  which 
it  is  associated  with  other  organisms  are  seen.  Indeed,  some  authori- 
ties believe  that  joint  involvement  cannot  occur  except  through  asso- 
ciated pyogenic  organisms,  especially  the  .Streptococcus  pyogenes. 

The  joint  lesions  may  ensue  upon  any  other  complication  or  acci- 
dental infection  with  the  gonococcus.     This  is  particularly  true  in 


GONOCOCCAL  ARTHRITIS 


251 


conjunctivitis  in  children  followed  by  arthritis.  Sometimes  the 
passing  of  sounds  through  strictures  which  are  still  infective  will  open 
the  avenue  for  absorption  and  arthritis.  Th(!  writer  has  seen  one 
such  case,  where  polyarthritis  ensued  npon  premature  passage  of  a 
sound  before  the  bacteriology  of  the  condition  was  known. 

Pathology. — The  gonococcus  with  its  allies  is  deposited  and  grows 
within  the  joint,  as  the  essence  of  the  process,  and  therein  makes 
changes  in  the  synovia,  joint  tissues  and  even  bone  substance  in  the 
familiar  and  characteristic  way.     Exudate  is  apt  to  appear,  sterile 


Fig.  61. — Author's  case  of  gonococcal  dorsolumbar  spondylarthritis.  Absence  of 
cartilage  spaces  indicates  bony  ankylosis  and  loss  of  lime  salts  in  the  bodies  of  the  ver- 
tebrae, defined  by  faint  shadows,  indicates  atrophy  of  long  disuse.  The  sacroiliac  region 
of  this  patient  is  shown  in  Fig.  62. 

early,  later  containing  the  gonococci  and  finally  again  sterile.  They 
may  frequently  be  found,  however,  by  sedimenting,  centrifugmg  and 
culturing,  and  no  diagnosis  is  final  without  these  steps.  In  joint 
lesions  the  gonococcal  complement  fixation  test  of  Schwartz  is  of 
particular  value,  probably  because  the  disease  is  one  of  absorption. 
The  organisms  have  been  found  in  the  scrapings  of  joints,  previously 
negative  to  aspiration.  Thus  negative  fluid  is  not  absolute  proof  of 
the  absence  of  the  organism  in  the  joint. 

Temporary  lesions  occm*  only  in  very  mild  cases,  including  arthralgia 
and  arthrosynovitis,  which  apparently  rarely  reach  the  stage  of  exuda- 


252     COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

tion  in  any  cjreat  deirroo.  IVrniancMit  lesions,  on  the  otlier  liand,  are 
much  more  eonnnon  anil  in  the  milder  decrees  resnlt  in  fine  fibrous 
adhesions,  but  in  the  jjreater  dejjrees  in  dense,  fibrous  and  even  bony 
ankylosis  after  destruetion  of  the  eartilages.  The  associated  lesions 
are  the  secondary  changes  of  disuse  in  the  muscles  which  become 
flabby,  ]iaretic  and  e\en  atro])hic,  and  the  antecedent  lesions  of  the 
gonococcus  from  which  the  joint  involvement  ])rocee(led. 


Fig.  (J2. — Author's  case  of  gonococcal  sacroiliac  spoudj  laithritis.  Loss  of  shadow 
of  lime  salts  indicates  atrophy  of  disuse  and  loss  of  cartilat^c  space  proves  bony  sacro- 
iliac ankylosis.     The  lumbar  region  of  this  patient  is  shown  in  Fig.  Gl. 


The  pathological  varieties  are  arthralgia,  synovitis,  arthritis,  osteo- 
arthritis and  polyarthritis.  Arthralgia  is  really  a  neuralgia  of  the 
joint  and  has  no  described  lesions.  It  may  be  neuritic  or  mildly  syno- 
vitic  and  naturally  leads  to  full  recovery.  Synovitis  or  arthrosynovitis 
is  practically  hydroarthrosis,  in  which  the  synovia  alone  is  attacked, 
followed  by  puffy  swelling,  copious  exudate  usually  of  serum  or  sero- 
pus,  never  of  pus  alone.  The  knee  is  the  usual  \'ictim  with  delayed 
full  recovery.  Arthritis  involves  all  the  elements  of  the  joints  more 
or  less,  with  rather  typical  purulent  exudate  followed  by  fibrous  adhe- 


GONOCOCCAL  ARTHRITIS 


253 


sions,  few  or  many,  slight  or  dense  and  disabling.  Osteoarthritis  adds 
involvement  and  destruction  of  the  cartilages  covering  the  bones,  and 
bony  ankylosis  as  a  sequel.  Polyarthritis  is  this  condition  in  the 
fingers  or  toes,  and  is  frequently  called  polyarthritis  deformans.  Com- 
monly the  distal  and  middle  joints  of  the  phalanges  are  invaded,  less 
frequently  the  metacarpophalangeal  or  metatarsophalangeal  articu- 
lations. Great  deformity  and  ankylosis  are  the  rule.  Mixed  infec- 
tion is  the  accepted  fact  in  the  last  two  forms. 


Fig.  63. — Gonococcal  arthritis.  Infiltrated  synovial  membrane,  with  numerous 
endocellular  gonococci  and  not  a  few  extracellular  gonococci  in  the  connective-tissue 
stroma.     (Finger.i)  ' 

Lovett^  notes  the  following  forms  of  joint  lesions:  (1)  Ai-thralgia 
without  definite  joint  lesions;  (2)  acute  serous  synovitis  with  much 
periarticular  swelling;  (3)  acute  fibrinous  or  plastic  synovitis,  with 
little  effusion;  (4)  chronic  serous  or  purulent  synovitis;  (5)  periarticu- 
lar involvement,  such  as  bursitis  and  tenosynovitis,  ^^^latever  the 
classification,  all  forms  may  merge  one  into  the  other,  without  great 
demarkation. 

Spondylarthritis  is  not  an  uncommon  manifestation  of  gonococcal 
disease  of  the  joints.  Figs.  61  and  62  show  the  x-v&j  photographs  of 
the  author's  case  of  spondylarthritis  in  whom,  diu-ing  a  very  severe 
attack  of  gonococcal  urethritis,  the  lower  dorsal  and  entire  lumbar 
spine  and  sacroiliac  joints  became  involved  intensely  and  finally 
ankylosed.     Tuberculosis  was  eliminated  by  every  known  examina- 

>  Die  Geschlects-Krankheiten,  1908. 
2  Keen's  Surgery,  1907,  p.  304. 


254     COMPLICATIONS  AND  SEQUELS  OF  ACUTE   URETHRITIS 

tion  and  test  and  sypliilis  by  the  absence  of  a  Wassonnann  reaction 
anil  all  other  clinical  signs.  The  .r-ray  report  by  l^r.  Byron  C.  Darling 
is  as  follows: 

"Spondylarthritis  or  spondylitis  deformans:  A  late  stage  of  spon- 
dylarthritis in  counterdistinction  from  hypertrophic  osteoarthritis, 
wliii-li  latter  is  characterized  by  spiu-s  or  lipping  of  the  bodies  of  the 
\"crtcbra\ 

"  1 .  The  poor  definition  and  lack  of  contrast  in  the  roentgenogram 
is  due  to  the  loss  of  lime  salts,  the  atrophy  of  disease  in  the  vertebrje, 
and  is  characteristic  of  the  condition.  The  cartilage  spaces  between 
the  i^osterior  articular  facets  of  all  the  hunbar  vertebrae  are  absent, 
indicating  bony  ankylosis. 

"2.  The  sacroiliac  region  shows  obliteration  of  the  cartilage  space 
between  the  sacrum  and  the  ilium,  with  com])lete  bony  fusion  and  the 
same  loss  of  lijne  salts  from  atrophy  of  disuse." 

Symptoms. — Local  and  systemic,  subjective  and  objective,  manifes- 
tations occur.  The  local  subjective  symptoms  are  pain,  heat,  swelling 
and  disability.  The  pain  Is  prominent  mostly  in  the  morning,  when, 
after  a  night's  sleep,  the  joints  are  distiu-bed  by  motion.  It  is  rela- 
tively least  in  arthralgia  and  synovitis,  and  greatest  in  arthritis  and 
subvarieties.  It  may  be  sharp  and  cutting  or  intense  and  incapacitat- 
ing, leading  to  spasm  of  the  muscles  in  fixation  of  the  joints.  In  the 
old  chronic  cases  the  pain  may  be  discomfort  aroused  to  acute  violence, 
sudden  exertion  or  exposure.  Heat  is  marked  and  proportional  with 
the  severity  of  the  attack,  and  its  recency,  declining  with  the  age  of 
the  case. 

Swelling  is  absent  in  arthralgia,  but  appears  with  synovitis  some- 
times to  a  great  degree  and  is  always  present  in  the  acute  or  relapsing 
stages  of  chronic  arthritis.  It  is  represented  by  exudate  into  the 
cavity  of  the  joint  and  congestion  and  edema  of  the  joint  substance 
and  annexa.  In  recent  cases  tension  and  fluctuation  or  "dance- of 
the  patella"  and  in  old  cases  thickening  around  the  joint  are  seen. 

Disability  is  due  to  pain,  swelling,  adhesion  and  muscular  spasm. 
In  arthralgia  the  sharp  neuralgic  pains  in  neuropathic  indiN'iduais 
are  much  complained  of  as  disabling  and  sometimes  become  a  veritable 
neurosis  of  incapacity.  In  hydroarthrosis  the  accumulation  may 
mechanically  prevent  motion,  while  in  arthritis  the  fibrinous  adhe- 
sions physically  Imiit  it  and  their  pain  on  tension  rcflcxly  checks'  it. 
Bony  ankylosis  speaks  for  itself  as  a  source  of  disabilit}^  Muscular 
spasm  is  seen  during  the  acute  stages  as  a  reflex  protection  of  the 
invaded  joint,  alike  in  this  as  in  all  other  articular  conditions,  inflam- 
matory or  traumatic. 

The  subjective  systemic  symptoms  are  those  of  absorption.  The 
patient  has  malaise,  nervous  depression  and  often  irritability.  Com- 
plaint of  the  atrophy  of  disuse  and  of  the  attendant  reflexes  and 
spasms  is  often  made.  In  arthralgia  these  symptoms  are  less  manifest 
and  of  a  higher  grade  in  synovitis  and  still  more  severe  in  arthrosyno- 
vitis,  arthritis,  osteoarthritis  and  polyarthritis.     Such  a  rule  would  be 


GONOC'OCCA. L  A  fiT/f  fil  TfS  255 

expected  because  these  lesions  usually  indicate  absorption  in  ascendinj^ 
amounts  and  increasing  activity  of  the  local  complication.  The 
objective  systemic  symj)toms  simply  verify  the  foregoing  statement 
b.y  the  patient,  and  it  will  be  found  that  many  of  them  run  a  low  grade 
of  fever  and  that  a  large  majority  of  the  more  severe  cases  have  a 
positive  gonococcal  complement  fixation  test. 

The  local  objective  symptoms  vary  with  the  stages  of  the  disease. 
In  the  acute  period  there  are  redness,  swelling  and  edema  of  the  skin 
and  joint,  reflex  fixation,  tenderness  and  pain,  and  in  the  chronic 
periods  there  are  infiltration,  bogginess,  crepitation,  adhesions  and 
ankylosis.  These  symptoms  vary  in  degree  and  relation  with  the 
severity  of  the  infection.  They  are  least  in  arthralgia  and  greatest 
in  arthritis,  osteoarthritis  and  polyarthritis.  Atrophy  of  the  muscles 
with  depression  or  exaggeration  of  reflexes  about  the  affected  joint  is 
a  late  manifestation  of  severe  cases.  When  spondylarthritis  occurs 
the  disability  and  other  attendant  symptoms  are  most  marked.  The 
original  urethritis  and  its  complications  belong  to  the  local  objective 
symptoms. 

The  termination  is  favorable  as  to  life  unless  the  general  infection 
is  so  severe  as  to  lead  to  septicemia  and  death,  in  which  the  arthritis 
becomes,  therefore,  only  a  small  element.  It  is  favorable  or  unfavor- 
able as  to  the  joint  in  accordance  with  the  severity  of  the  lesion.  Full 
recovery  follows  arthralgia,  except  in  the  rare  victims  of  neurosis  or 
of  joints  irritable  to  exposure  and  exertion.  Arthrosynovitis  follows 
the  same  rule,  but  with  greater  tendency  to  nonresistant  joints.  In 
arthritis  and  its  extensions  into  osteoarthritis  and  polyarthritis  defor- 
mans the  permanent  damage  is  great  and  there  is  hardly  any  limit  to 
the  secondary  lameness.  Many  patients  are  seen  who  for  life  must 
endure  the  loss  of  half-function  in  a  number  of  joints.  The  ■s\Titer 
had  a  man  in  whom  50  per  cent,  of  one  elbow,  25  per  cent,  of  the  other 
elbow,  10  per  cent,  of  one  shoulder,  25  per  cent,  of  one  ankle  and  about 
the  same  amount  of  one  hand  w^ere  lost  in  function  for  life. 

As  in  other  forms  of  artlu-itis,  relapses  are  very  common,  frequently 
under  slight  or  even  unknown  cause. 

Diagnosis. — The  presence  of  m-ogenital  gonococcal  foci  or  compli- 
cations must  always  be  searched  for  and  studied.  As  already  pointed 
out,  gonococci  have  been  found  in  the  blood  of  many  victims  of  pos- 
terior urethritis  and  its  sequels.  It  is,  on  the  other  hand,  not  neces- 
sary for  septicemia  or  bacteremia  to  be  present  for  arthi-itis  and  its 
analogues  to  arise.  Careful  bacteriological  research  must  always  be 
exercised  toward  gonococcal  lesions,  and  also  toward  fluid  aspu'ated 
from  the  affected  joints,  tendon  sheaths  and  the  like,  as  many  authori- 
ties believe  it  is  the  associate  organisms,  notably  the  streptococcus, 
which  render  the  arthritis  possible.  It  is  a  safe  rule  to  say  that  few 
or  no  locomotory  complications  should  be  recognized  as  indubit- 
ably gonococcal,  unless  the  organism  has  been  recovered  from  the 
antecedent  foci,  and  from  the  affected  joints  after  repeated  search 
and  combined  with  a  positive  gonococcal  fixation  test.    The  history, 


250     COMPLICATJUXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

tlierofore,  involves  either  h>]X'racute  or  loiifi-continued  active  chronic 
urethritis,  both  with  their  ai)])r()])riate  coni])heatioiis  anil  other  symp- 
toms of  absor]>tion.  The  subjective  symptoms  pass  from  those  of  the 
lu'ethritis  o\'er  into  those  of  the  systemic  invasion  with  deposit  of 
active  disease  in  the  joints,  chiefly  pain,  spasm,  disability,  fixation  and 
"creakinfi;."  Tlie  objective  signs  nmst  detect  the  focus  from  which 
the  disease  proceeds,  its  presence  in  the  joint  by  heat,  redness,  swelling, 
fluid,  crepitation  and  muscular  rigidity,  and  if  necessary  its  precise 
nature  is  shown  by  withdrawing  the  fluid  for  the  laboratory.  The 
laboratory  investigation  simply  recognizes  the  morphology  and  culture 
characters  of  the  recovered  organism.  Examination  of  the  blood  for 
the  gonococcal  complement  fixation  test  is  almost  always  positive. 
Treatment  aids  the  diagnosis  in  the  point  that  very  rapid  subsidence 
of  the  synovial  inflammation  upon  surgical  or  other  treatment  of  a 
focus  of  gonococcal  infection  pro^'es  the  connection  between  the  two 
lesions. 

Keyes^  gives  the  following   table  of  distinction  between  common 
and  gonococcal  urethritis. 


TABLE   OF  DIFFERENTIAL  DIAGNOSIS  BETWEEN  GONOCOCCAL  AND 
SIMPLE   EHEUMATISM. 


Gonococcal  Rheumatism. 

1.  Cause:  gonorrhea.  No  influence  of 
cold  in  the  production  of  the  rheumatism. 

2.  Very  rarely  observed  in  women. 

3.  Nonfebrile,  or  much  less  so  than 
simple  rheumatism.  Even  in  acute  cases 
reaction  ne\-er  attains  the  habitual  in- 
tensity of  rheumatic  fever. 

4.  Symptoms  habitually  limited  to  a 
small  number  of  joints.  The  affection 
never  becomes  general  to  the  same  extent 
as  does  simple  rheumatism. 

5.  Less  movable  than  simple  rheuma- 
tism, going  from  one  joint  to  another  less 
quickly.  No  delitescence;  no  real  jumping 
from  one  joint  to  another. 

6.  Local  pains  generally  moderate, 
always  less  than  in  simple  rheumatism; 
sometimes  remarkedly  indolent. 

7.  Frequently  a  tendency  to  hydrar- 
throsis foUowing  the  acute  fluxion. 

8.  No  sweating. 

9.  LMne  not  modified. 

10.  Blood  not  furnishing  a  marked 
buffy  coat. 

11.  Cardiac  complications  exceptional. 

12.  Frequent  coincidence  with  a  special 
ophthalmia,  inflammation  of  the  synovial 
sheaths  of  the  tendons,  inflammation  of 
the  bursa,  etc.  The  latter  localities  may 
be  exclusively  implicated. 

13.  Relapse  in  the  course  of  successive 
gonorrheas  very  frequent. 


Simple  Rheumatism. 

1.  No  etiological  relation  with  the 
state  of  the  urethra.  Habitual  causes 
cold,  inheritance,  rheumatic  diathesis,  etc. 

2.  Common  in  the  female,  although 
less  frequent  in  the  male. 

3.  Reactional  phenomena  much  more 
intense  and  prolonged  than  in  gonorrheal 
rheumatism. 

4.  Symptoms  usually  involve  a  num- 
ber of  the  articulations;  sometimes  nearly 
all  of  them. 

5.  Symptoms:  movable,  ambulatory 
fluxions;  rapid  delitescence,  jumping 
from  one  joint  to  another. 

G.  Pains  always  rather  intense,  some- 
times excessive,  disappearing  less  rapidly 
than  those  of  gonorrheal  rheumatism. 

7.  Little  or  no  tendency  to  consecu- 
tive hydrarthrosis. 

8.  Abundant  sweats,  constituting  a 
symptom  almost  essential  to  the  malady. 

9.  Urine  specially  modified. 

10.  Blood  forming  a  firm,  concave  clot 
with  buffy  coat. 

11.  Cardiac  complications  frequent. 

12.  Acute  rheumatism  does  not  affect 
the  eye;  the  burste  escape,  as  do  usually 
the  sheaths  of  the  tendons. 


13.  Relapse  frequent,  but  always  inde- 
pendent of  the  state  of  the  urethra. 


'  Geni to-urinary  Diseases,  1905,  p.  55. 


GONOCOCCAL  ARTJIRJTIH  257 

The  author  would  add  four  other  distinctions: 

14.  Gonococci  in  urethral  discharf;e  or  14.  No  gonococci. 
seminal    vesicular    secretions,  sometimes 

in  the  urine  in  males  and  in  the  vulvo- 
vaginal glands,  cul-de-sac  of  the  vagina, 
cervix  uteri  and  also  urine  of  women. 

15.  Aspiration  of  joint  frequently   re-  15.  No  gonococci  in  fluid  of  joint, 
veals  the  gonococcus. 

16.  Gonococcal  complement  fixation  test  16.  Gonococcal  complement  fixation 
positive.                                                                      test  absent. 

17.  Condition  of  tonsils  or  teeth  not  a  17.  Tonsils  or  teeth  often  source  of 
factor.                                                                          infection. 

Treatment  of  Arthritis,  Periarthritis,  Myositis,  Bursitis  and  Chondritis. — 
In  these  important  conditions  the  prophylaxis  is  preeminently  proper 
and  active  attention  to  the  urethritis  and  its  complications,  notably  in 
the  prostate  and  the  seminal  vesicles,  which  should  receive  regular 
examinations  during  a  posterior  urethritis  for  detection  for  the  earliest 
onset  of  disease.  Cautious  instrumentation,  avoidance  of  all  traumatism 
and  selection  of  conservative  methods  of  treatment  of  urethritis  and 
these  complications  all  belong  to  prevention  of  systemic  invasion  and 
secondary  synovial  complications,  because  any  injury  of  the  mucosa 
during  active  infection  is  a  wide-open  portal  of  absorption.  Abortion 
is  nil  but  active  and  proper  treatment  of  a  joint  or  tendon  sheath  at  the 
first  sign  may  practically  prevent  extension. 

Curative  Treatment — Curative  treatment  respects  the  findings  of 
both  pathology  and  symptomatology.  The  pathological  indications 
must  confine  the  inflammation  to  the  serous  and  delimit  it  from  the 
purulent  type  and  in  addition  prevent,  if  possible,  more  than  a  true 
synovitis  in  contrast  with  panarthritis  or  pantenosjmovitis  with 
secondary  adhesions  and  sometimes  ankylosis.  In  short,  the  lesions  are 
restricted  to  the  temporary  and  excluded  from  the  permanent  tj^^e. 

The  symptomatic  indications  maintain  and  relieve  the  mild  as  con- 
trasted with  the  severe  symptoms  and  decrease  the  pain,  spasm  and 
hydrarthrosis  and  the  systemic  absorption  and  symptoms  which  denote 
continued  activity  of  the  antecedent  focus.  Prompt  resolution  is  stimu- 
lated instead  of  delayed  recovery  and  above  all  the  symptoms  and 
infection  of  the  primary  focus  must  be  relieved  after  the  methods 
already  described  under  each  head. 

The  management  secures  the  benefit  of  cleanliness,  asepsis  and  anti- 
sepsis in  good  hygiene  and  the  great  essential  is  rest  in  bed  to  abate  the 
inflammation  as  a  whole  and  splinting  of  the  parts  to  soothe  the  pain, 
spasm  and  local  inflammation.  Exercise  is  forbidden  until  the  process 
is  termmated  and,  as  in  ordinary  rheumatism  and  gout,  selected  diet  and 
drink  are  necessary  although  of  comparatively  less  value.  Nursing  at 
least  durmg  the  acute  period  had  best  be  special  and  even  later  when 
massage  and  other  physical  means  are  useful. 

The  physical  measures  are  among  the  most  unportant  and  selected 

according  to  stage  of  the  disease.    IMassage  is  for  the  chronic  period  and 

keeps  the  muscles  m  health,  prevents  their  atony  and  even  atrophy  as  a 

substitute  for  voluntary  exercise.    Various  ointments  may  be  applied 

17 


25S     COMPLICATIONS  AND  SEQUELS  OF  ACUTE   URETHRITIS 

diirhig;  the  massage,  of  which  salicylic  acid  (2  to  4  per  cent.),  ichthyol 
and  iodoform  are  examples.  Passive  motion  of  the  joints  as  jiart  of 
tlie  massage  beginning  Avith  slight  and  adding  increasing  degrees  is 
necessary  and  in  severe  cases  mechanical  treatment  Avith  the  various 
vibratory  and  manijnilatijig  machines  is  excellent.  IIydrotherai)y 
employs  moist  heat  or  cold.  Hot  fomentations,  poultices  and  douches 
are  comforting  and  counterirritant  and  antiseptic  wet  dressings  may  be 
combined  with  them.  Cold  succeeds  when  heat  may  fail  and  may  be 
employed  with  the  ice-bag  or  the  cold-water  coil.  In  the  reco\ery 
period  when  absorption  and  elimination  are  indicated  hot,  general  and 
Turkish  baths  are  of  value.  Baking  the  affected  member  in  a  Avell- 
designed  and  operated  hot-air  apparatus  is  very  efficient  and  Bier's 
liA-peremic  method  applied  for  at  least  thirty  minutes  two  or  three 
times  a  day  is  a  prized  adjuvant.  Strapping  for  sui)port  and  uniform 
pressure  is  in  the  later  stages  comforting  and  strengthening. 

The  heliotherapy  consists  in  applying  a  500  c.  p.  lamp  to  the  afli'ected 
joints  and  their  annexa  for  from  fifteen  to  thirty  minutes  several  times 
a  day  as  a  decongestant  and  counterirritant.  So  strong  a  lamp  must 
never  be  at  rest  but  always  in  motion,  waving  back  and  forth  over  the 
skin.     Intense  redness  without  blister  is  sought. 

The  electrotherapy  may  be  the  hot-coil  applied  to  the  affected  joint 
for  the  indications  of  thermic  action  or  preferably  diathermy  is  applied 
daily  in  the  manner  previously  described  mider  septicemia.  For 
stiffened  joints  the  indirect  static  spark  is  generously  and  persistently 
applied  at  first  daily,  then  three  times  a  week. 

The  medicinal  measures  treat  the  antecedent  point  of  gonococcal 
absorption  along  recognized  and  already  described  lines  and  by  systemic 
application  any  and  all  standard  antirheumatic  medicines  may  be 
administered — always  up  to  physiologic  action  and  without  disturbing 
the  general  nutrition  of  the  patient.  While  relatively  of  less  value  in 
gonococcal  arthritis  than  in  other  forms  perseverance,  full  doses, 
changes  and  combinations  in  selection  often  produce  results.  The 
indications  are  catharsis  with  salines,  diaphoresis  with  aspirin,  urinary 
antisepsis  with  boric  acid,  biborate  of  soda,  benzoic  acid,  benzoate  of 
soda,  or  hexamethylenamin,  alteration  with  iodide  of  potash  and  mer- 
cury, and  support  with  quinine,  strychnine  and  iron.  The  best  anti- 
rheumatics are  oil  of  wintergreen,  colchicum,  salicylate  of  soda  and 
salicylic  acid  combined  with  bicarbonate  of  soda.  Alkaline  mineral 
waters,  such  as  French  Vichy,  freely  taken  are  very  good. 

By  local  application  during  the  fomentations  and  bakings  counter- 
irritation  may  be  employed,  with  oil  of  wintergreen,  turpentine, 
guaiacol  and  eucal^-ptus.  Iodine  may  be  painted  on  or  administered  in 
ointment.  Other  salves  are  20  to  50  per  cent,  ichthyol  and  iodoform. 
Blisters  from  the  actual  cautery,  strong  iodine  and  cantharides,  kept 
open  by  strong  salves  may  be  used  but  incur  the  risk  of  cellulitis  through 
the  break  in  the  skin.  Intense  counterirritation  ma>'  be  employed  by 
"stripping"  the  joint  with  the  actual  cautery  without  blisters.  Injec- 
tion of  bursoe  with  a  few  drops  of  pure  carbolic  acid  has  been  tried  in 


GONOCOCCAL  ARTHRITIS  259 

sacs  not  related  to  joints,  such  as  the  })nrsti3  beneath  the  tejidr*)!  of 
Achilles. 

Semmtherapy  appears  to  give  its  greatest  success  in  synovial  compli- 
cations and  its  methods  are  detailed  in  the  following  paragraphs. 
Autogenous  or  heterogeneous  serums  and  bacterins  may  be  tried 
with  favor  toward  the  former  unless  they  fail  and  among  the  latter 
toward  the  mixed  or  associated  bacterins,  such  as  Van  Tott's.  The 
secret  of  success  is  regular  periods  of  administration,  slowly  ascend- 
ing doses,  no  negative  phase  or  other  severe  reaction  and  rather  large 
doses  toward  the  end  of  the  course  with  proper  respites  between  courses. 
The  treatment  may  be  laid  down  according  to  the  chart  described  in 
later  pages  of  this  chapter.  The  chronic  and  subacute  periods  are  better 
than  the  acute  on  account  of  the  likelihood  of  negative  phase  with 
increased  symptoms.    Bacterins  are  better  than  serums. 

The  surgical  measures  are  nonoperative  and  operative.  Support  of 
the  part  with  splints  and  casts  introduced  nonoperative  procedures 
associated  with  wet  dressings — antiseptic,  such  as  aluminum  acetate, 
or  sedative,  such  as  lead  and  opium  wash.  Leeches  will  decongest. 
Operative  technic  is  based  on  incision,  evacuation,  cleansing  and  suture 
of  joint,  tendon  sheath  or  bursse  with  the  tendency  of  opening  the  part 
as  little  as  possible  on  the  principle  of  Scriba,^  w^hose  operation  consists 
of  entering  the  joint  with  two  small  trochars  and  cannulse  at  opposite 
sides  to  permit  through  and  through  irrigation  first  with  a  cleansing 
fluid  followed  by  hot  bichloride  of  mercury  1  to  5000  until  all  pus  is 
removed.  The  wounds  by  the  trochars  are  stitched  up  and  a  dressing 
and  splint  applied.  The  knee  is  the  best  joint  for  this  treatment.  Resec- 
tion of  the  joint  and  removal  of  the  tendon  sheath  are  reserved  for  the 
oldest  and  most  marked  cases. 

J.  Scriba  gives  a  series  of  cases,  of  which  one  was  suppuration  of  the 
knee  with  gonorrhea  of  four  wrecks'  standing.  This  was  not  a  mere 
coincidence  as  the  patient  suffered  from  "acute  articular  rheumatism." 
Double  incision  on  each  side  of  the  patella  and  irrigation  with  5  per  cent, 
phenol  were  carried  out.  This  procedure  was  years  before  Neisser 
demonstrated  the  gonococcus.  This  case  seems  to  be  one  of  the  first 
if  not  the  first  application  of  double  opening  and  irrigation  of  the  knee- 
joint  in  gonococcal  arthritis.  The  credit  of  this  procedure  to  Keyes, 
as  is  made  in  Watson  and  Cunningham's  work.  Diseases  and  Surgery 
of  the  Genito-urinary  System,  1908,  p.  72,  is  stated  by  E.  L.  Keyes,  Jr., 
in  a  personal  communication  to  the  author  to  be  an  error  and  the 
method  to  be  one  which  he  himself  has  never  employed. 

Aftertreatment. — Immediate  aftertreatment  demands  cure  of  the 
urethritis.  Its  relief  may  antedate  that  of  the  s^^lOvial  complications. 
Restoration  of  the  synovial  membrane  and  elements  of  the  jouit  to 
the  nearest  possible  normal  condition  is  the  standard.  Gradual 
increase  in  passive  motion  followed  by  mild  and  the  increasmg  volun- 
tary exercise.     Adhesions  should  be  gradually  broken  up  by  this 

1  Ueber  die  Gonarthrotomie  und  ilire  Indikationen,  etc.,  Berl.  klin.  Wcbnschr.,  1S77, 
xiv,  640. 


260     COMPLICATIOXS  AND  SEQUELS  OF  ACUTE  URETHRITIS 

])rticess  or  uiulor  ether  an  eH'ort  to  coiitiiuie  normal  metabolism  con- 
tinued with  proper  diet,  habits  and  drinks.  Alkaline  mineral  waters 
are  of  great  value.  Operative  cases  receive  standard  and  appropriate 
care  and  every  patient  should  avoid  ex]iosure  to  cold,  wet,  strain, 
injury  and  overexertion,  because  synovial  nuMn])ranes  once  infected 
are  very  susceptible  to  relapse  or  attacks  of  simple  inflammation  from 
such  causes. 

The  remote  aftertreatment  comprises  general  conniion  sense  con- 
cerning the  health,  strength  and  resistance  of  the  ])atient  and  above 
all  absolute  avoidance  of  fresh  gonococcal  infectioji  because  such  an 
incident  would  almost  be  sure  to  be  followed  by  absorption  and  renewed 
arthritis.    The  so-called  rheumatic  diathesis  should  recei^'e  attention. 

Cure. — Cure,  pathologically,  in  mild  cases  is  probably  absolute  but 
in  severe  infection  restricted  and  limited  according  to  essential  destruc- 
tion of  elements  of  joint,  tendon  sheath  or  bursa.  Symjjtomatically 
there  should  be  no  pain,  fluid,  crepitation  or  adhesions  and  full  or  nearly 
full  function  and  bacteriologically  the  gonococcus  must  l)e  absent  in  the 
antecedent  urethral  focus  and  in  the  s^'novia. 


COMPLICATIONS  OF  NONGONOCOCCAL  ACUTE  URETHRITIS. 

Classification. — There  is  a  close  similarity  between  these  complica- 
tions and  those  of  gonococcal  anterior  and  posterior  urethritis.  There 
is,  therefore,  a  m'ogenital  group  in  which  the  lesions  affect  the  organs 
of  the  sexual  and  the  urinary  systems,  so  that  both  the  genital  form 
and  urinary  forms  are  recognized.  In  most  of  the  nongonococcal 
infections,  however,  the  iu"inary  organs  are  much  less  frequently 
affected,  either  by  the  initial  lesion  or  by  its  complications.  The 
chief  exception  is  the  suppurative  conditions.  A  systemic  group  is 
also  recognized  in  which  the  organs  of  the  extraiu'ogenital  systems  are 
invoh'ed.  The  much  less  se\ere  character  of  the  nongonococcal  mani- 
festations makes  such  complications  extremely  rare;  but  it  is  well  to 
bear  these  facts  in  mind.  The  rarity  of  all  these  conditions  is  the 
reason  for  their  very  brief  treatment  in  this  work. 

Varieties. — Varieties  as  given  in  the  clinical  section  are  traumatic, 
catarrhal,  diathetic,  erupti\'e,  pyogenic,  syphilitic  and  chancroidal. 
Each  of  these  is  important  but  the  general  principle  of  treatment  is  so 
closely  that  of  gonococcal  complications  that  such  principle  is  assumed 
in  tlie  following  paragraphs  and  only  differences  and  distinctions  noted. 

Significance. — Significance,  in  general,  is  chiefly  minor  except  the 
syphilitic  because  this  is  essentially  a  systemic  disease,  and  chan- 
croidal because  it  often  leads  to  operation  on  the  glands  of  the  groin, 
and  pyogenic  because  it  may  be  as  vicious  as  the  gonococcal  compli- 
cations. The  pyogenic,  therefore,  closely  resembles  the  gonococcal 
in  severity  and  character  while  catarrhal  does  so  in  type  but  less  in 
intensity,  although  its  dm-ation  and  intractability  often  suggest  the 
gonococcus.     Traimiatic,  diathetic  and  eruptive,  may  be  nonbacterial, 


COMPLICATIONS  OP  NONGONOCOCCAL  ACUTE  URETHRITIS     201 

consist  in  urethritis  alone  and  often  have  no  complications,  in  which 
feature  catarrhal  lesions  share.  Traumatic  inflammation  of  the 
urethra  may  induce  epididymoorchitis  and  cystitis  or  make  anterior 
disease  posterior.  As  previously  stated  in  the  clinical  section,  minor 
complications  invade  the  foreskin  alone  or  the  mucosa  of  the  urethra 
alone,  whereas  major  complications  compromise  the  sexual  glands  and 
the  organs  of  the  urinary  system  or  the  general  system. 

Minor  complications  are  therefore  classified:  (1)  Phimosis;  (2) 
paraphimosis;  (3)  balanitis;  (4)  posthitis;  (5)  balanoposthitis,  which 
may  occur  in  any  of  the  nongonococcal  forms  of  infection;  CO)  folli- 
culitis seen  chiefly  in  the  catarrhal  and  pyogenic;  (7)  lymphangitis; 
(8)  lymphadenitis  developing  rarely  in  the  catarrhal,  more  frequently 
in  the  pyogenic  and  invariably  in  the  syphilitic  and  chancroidal  lesions. 

Their  treatment,  in  general,  is  the  same  as  that  for  the  gonococcal 
complications  modified  to  meet  particular  conditions.  The  removal 
of  the  cause  is  essential  in  traimiatic,  so  that  solutions  too  hot  or  too 
concentrated  and  instruments  too  large,  rusty  or  imperfect,  and  their 
application  too  violent  are  instantly  stopped.  Care  of  the  health  and 
addition  to  resistance  are  required  in  catarrhal,  diathetic  and  eruptive 
forms.  Catarrhs  elsewhere  in  the  body  are  often  keys  of  the  problem 
and  attacks  of  glycosuria  and  uric  acid  poisoning  should  be  abated  as 
part  of  the  treatment  of  the  complications.  Surgical  dressings  are 
required  in  chancroidal  and  syphilitic  manifestations,  to  which  may  be 
added  incision  of  the  glands  in  the  groin  for  abscess  and  active  anti- 
syphilitic  systemic  treatment.  Pyogenic  complications  require  the  full 
management  and  all  the  measures  prescribed  for  gonococcal,  because 
except  for  the  infecting  organisms  there  is  no  definite  distinction 
between  the  two. 

Major  complications  in  the  sexual  forms  include  these  classes: 
Cowperitis,  prostatitis,  seminal  vesiculitis,  epididymoorchitis  and 
funiculitis  and  in  the  urinary  forms  urethrocystitis,  cystitis,  urethritis, 
pyelitis  and  pyelonephritis. 

The  cowperites  are  reserved  for  the  catarrhal  rarely  and  the  pyogenic 
very  commonly,  and  prostatitis  is  occasional  in  traumatic,  more  usual 
in  catarrhal  and  still  more  common  in  the  pyogenic.  Seminal  vesi- 
culitis is  produced  only  by  the  pyogenic,  to  W'hich  is  added  epididymo- 
orchitis, which  may  also  be  syphilitic.  The  urinary  forms  are  seen  in 
descending  order  of  frequency  in  the  pyogenic,  catarrhal  and  s^^philitic 
complications.  Careful  distinction  must  be  drawn  between  the 
catarrhs,  which  are  the  terminal  stage  of  other  complications  and  the 
catarrhs  which  originating  as  such  in  the  m'ethra  extend  into  the 
annexa  or  upward  along  the  urinary  tract. 

Treatment  in  general  means  that  all  these  complications  deviate  but 
little  from  the  methods  and  measm^es  set  down  for  those  of  gonococcal 
origin  on  the  ground  that  the  pyogenic  germs  are  the  prevailing  infec- 
tion. In  particular  the  sm*gery  of  these  cases  is  in  no  wise  different. 
Catarrhal  forms  require  combat  of  this  peculiar  weakness  by  sustain- 
ing the  health  and  restoring  low-grade  bodily  strength  and  s^^hilis 


2C>2^COMPLICATIOXS  AXD  SEQUELS  OF  ACUTE   URETHRITIS 

I'eqiiives  active  measures  with  iiieroury,  iodides,  the  newer  arsenical 
preparations,  general  sii])port  and  hygiene. 

Cure,  pathologically,  in  full  restoration  of  the  parts  may  be  possible 
in  the  milder  lesions,  snch  as  traumatic,  catarrhal,  diathetic  and  erup- 
tive, but  it  is  not  possible  in  more  destructive  jnogenic,  syphilitic  and 
chancroidal  disease.  Symi)toniatica]ly,  howcNcr,  relief  from  suffering 
and  symptoms  is  usually  attained  except  in  the  more  profound  pyo- 
genic disease  and  bacteriological  eradications  of  organisms  and  relief 
from  the  i)ositive  signs  in  the  blood  test  are  the  measures  of  good 
results. 


CHAPTER   IV. 
CHRONIC  URETHRITIS. 

General  Clinical  Features. — Definition  and  General  Principles. — 
Chronic  inflammation  of  the  urethra  at  any  point  and  due  to  any  cause 
may  properly  be  described  as  chronic  urethritis,  a  condition  in  which 
the  lesions  are  either  more  or  less  stationary  with  relapses,  or  slowly 
progressive  with  exacerbations.  It  is  rather  well  to  fix  this  general 
conception  in  the  mind  and  then  to  distinguish  each  unportant  kind 
as  to  symptoms,  diagnosis  and  treatment. 

Varieties. —As  already  stated  the  clinical  forms  are  stationary  with 
relapses  and  progressive  with  exacerbation.  Cure  is  possible  in  each 
type,  but  usually  the  mucosa  is  permanently  changed  in  various  ways 
and  degrees  which  are  sequels  and  will  be  so  described  in  this  work. 

As  to  location  and  extension,  there  are  recognized  anterior  and 
posterior,  anteroposterior  or  general  and  localized,  that  is,  confined  to 
definite  single  or  multiple  points  either  the  anterior  or  the  posterior 
portions  of  the  canal  or  both. 

As  to  cause,  nonbacterial  and  bacterial,  of  which  the  latter  is  practi- 
cally the  only  form  of  clinical  importance,  unless  one  regards  the 
relapses  of  catarrhal  urethritis  seen  in  many  patients  for  a  few  days 
after  instrumentation  as  examples  of  chronic  disease. 

The  varieties  of  nonbacterial  chronic  urethritis,  according  to  exci- 
tants, are  the  same  as  those  seen  in  acute  manifestations,  but  rest  on 
a  chronic  diathesis,  by  which  comparatively  simple  factors  may  lead 
to  long-continued  lesions:  (1)  Traumatisms,  thermal  from  too  hot  or 
too  cold  irrigations,  chemical  from  too  concentrated  applications, 
mechanical  from  too  rough  introduction  or  defective  forms  and  kinds 
of  instrument;  (2)  medicinal,  from  drugs  irritant  after  internal  admin- 
istration, such  as  balsams,  cantharides,  alcohol  and  tm'pentine  and 
after  eating  such  vegetables  as  asparagus,  rhubarb,  tomatoes,  straw- 
berries and  the  like;  (3)  physical,  from  the  use  of  instruments  too  hot 
or  too  cold,  with  rough  sm-faces  and  faulty  introduction. 

Traumatism  may  involve  any  healthy  mucosa,  but  is  most  potent 
in  the  unhealthy  cases  and  rests  on  the  use  of  rough,  rusty  or  ragged 
instruments  as  well  as  unskilled  and  forceful  manipulation.  The 
offense  of  an  indwelling  catheter  is  a  familiar  traumatism;  and  in  this 
class  belong  masturbation  and  sexual  excitement  without  coitus. 
Caution  should  always  be  exercised  to  pass  smooth  instruments  and 
with  gentleness,  never  to  use  applications  of  extremes  of  temperature 
or  concentration,  and  never  to  repeat  treatment  at  intervals  too 
short  for  a  recovery  period. 


264  CIIROXIC  URETHRITIS 

Of  bacterial  urethritis,  noiiiionococcal  and  gonococcal  varieties  are 
seen,  of  Avhich  the  former  have  the  same  general  but  far  more  mild 
features  than  the  latter,  so  that  the  latter  may  be  regarded  as  furnish- 
ing the  type  for  all  the  others  in  the  clinical  manifestation.  Chronic 
suppurative ,  nongonococcal  urethritis  may  duplicate  the  ravages  of 
the  gonococcus,  but  is  rare  and  needs  no  separate  discussion,  except 
to  note  that  the  pyogenic  organisms  alone  are  present. 

The  varieties  of  bacterial  chronic  lu'ethritis,  according  to  the  excit- 
ing organism,  diii)licate  those  given  in  the  list  of  causes  of  bacterial 
nongonococcal  acute  urethritis,  but  may  be  repeated  here:  ]\Iicro- 
coccus  catarrhalis  in  true  catarrhal  forms,  the  Treponema  pallidum 
in  s^'philitic  t^pes,  the  bacillus  of  Ducrey  in  chancroidal  in\asions, 
and  the  ordinary  pyogenic  organisms  in  simple  pus  cases,  Bacillus  coli 
conununis  being  often  seen.  Bacteria  are  doubtless  a  factor  in  the 
majority  of  cases,  hence  the  importance  of  bacterial  investigation. 

1.   GONOCOCCAL   CHRONIC   URETHRITIS. 

Significance.— As  in  acute  urethritis,  gonococcal  infection  will  be 
taken  as  the  type  and  its  two  varieties  of  anterior  and  posterior  will 
be  considered  together. 

Anterior  and  Posterior  Gonococcal  Chronic  Urethritis. 

Occurrence  and  Significance.- — The  general  characters  of  gonococcal 
infection  in  the  urethra  render  the  tendencj'^  to  persistence  of  the  pro- 
cess both  active  and  great.  It  may  be  safely  said  that  few  cases  are 
seen  without  more  or  less  protracted  subacute  or  terminal  stages, 
although  true  chronic  disease  may  not  ensue.  This  fact  is  true  in 
both  anterior,  posterior  and  anteroposterior  infections.  It  is  prob- 
able that  chronicity  is  most  common  in  the  posterior  m-ethra,  although 
in  older  writers  this  lesion  was  more  or  less  doubted. 

The  significance  of  truly  clu-onic  gonococcal  infection  in  both  sexes 
is  that  many  of  its  lesions  provoke  little  or  no  subjective  attention, 
invite  indifference  and  neglect  and  thus  lead  to  infection  of  the  opposite 
sex  in  the  marriage-bed.  There  is  practically  no  difference  between 
the  dangers  which  the  one  sex  may  offer  the  other  in  these  circiun- 
stances. 

Etiology. — The  fact  that  gonococcal  infection  of  the  mucosa  is  not  a 
superficial  catarrh,  but  a  vicious,  penetrating,  infiltrating  suppuration, 
is  now  fully  established  through  its  characters  of  exfoliation,  infiltra- 
tion, ulceration,  purulence,  complications  and  chronic  tendencies. 
This  pathogenic  nature  of  the  process  is  the  essential  or  exciting  cause. 
Among  the  predisposing  factors  are  the  ignorance  and  indiscretion  of 
patients  and  errors  in  diagnosis  and  treatment.  The  victims  are 
negligent  and  indifferent  in  their  management,  heedless  of  warning 
as  to  the  character  of  the  disease  and  sometimes  even  vicious  in  the 
chances  taken  of  infecting  the  innocent.     Their  occupation  is  often 


GONOCOCCAL  CHRONIC  URETHRITIS  205 

an  offense  to  the  inflammation.  One  of  the  worst  cases  the  writer 
has  ever  seen  was  in  a  raihoad  brakeman  whose  occupation  aided  the 
disease  in  wide  extension.  Indiscretions  are  also  coinmoii  during  the 
most  treacherous  and  uncertain  period — that  of  the  decHne.  Excesses 
in  alcohol,  diet  and  sexual  relations  are  not  uncommon.  Thus  from 
the  patient  little  or  no  cooperation  is  obtained. 

Errors  in  diagnosis,  which  are  commonly  those  of  failure  to  search 
for  the  gonococcus  by  smear  and  culture  and  for  absorption  by  the 
complement  fixation  test,  are  largely  responsible  for  many  uncured 
casco,  as  treatment  is  prematurely  discontinued  even  by  the  physician. 
Unduly  frequent  treatment  by  patient  and  physician,  with  concen- 
trated solutions,  improper  instruments  and  the  like,  tends  to  augment 
the  natural  tendency  of  the  disease  to  penetrate,  become  chronic 
and  complicated,  by  repeatedly  adding  to  the  infection  the  element 
of  thermic,  chemical  or  physical  trauma,  with  secondary  catarrhal 
inflammation. 

A  most  important  element  is  poor  resistance  of  the  patient  to  all 
ordinary  diseases  which,  instead  of  ending  quickly  and  fully,  are  apt 
to  be  protracted  into  long  periods.  Questions  concerning  his  general 
resisting  powers  should  always  be  asked  the  patient  as  an  element  in 
prognosis. 

A  minute  subdivision  of  causes  of  so  important  a  condition  as 
chronic  urethritis  cannot  well  be  inclusive  and  exclusive,  because  fac- 
tors in  some  instances  are  predisposing  and  systemic,  but  in  others 
exciting  and  local.  As  a  rule  the  same  factors  are  at  work  in  both 
the  nongonococcal  and  gonococcal  disease  in  producing  a  tendency 
to  chronicity.  The  predisposing  systemic  factors  are,  as  in  acute 
urethritis,  low  vitality ,^semi-invalidism  and  acute  or  chronic  alcoholism. 
Conditions  producing  hyperacid,  alkaline  or  crystalline  urine,  such 
as  gout,  rhemnatism,  diabetes  and  lithiasis,  constituting  the  so-called 
diathetic  urethritis,  are  also  important  in  the  presence  of  gonococcal 
invasion.  Tuberculosis  is  a  factor  in  depreciating  the  health  and 
strength,  as  also  are  unhealthful  occupations. 

Predisposing  local  factors  are  a  mucosa  vulnerable  by  previous 
attacks,  even  of  noninfective  urethritis  or  by  injury  or  any  other 
element  tending  to  leave  permanent  damage  locally.  Periurethral 
disease,  as  hypertrophy  of  the  prostate  in  the  male  and  in  the  female 
uterine  displacement,  laceration  and  deformity,  are  poor  grounds  of 
cure  in  acute  gonococcal  infection  and  directly  invite  the  chronic 
forms.  A  more  full  discussion  of  the  influence  of  all  these  factors  is 
given  in  the  Chapter  on  Acute  Urethi'itis  on  page  19. 

The  bacteriological  causes  are  familiar,  being  chiefly  the  gonococcus 
and  secondarily  its  usual  allies,  as  fully  discussed  under  Gonococcal 
Acute  Urethritis  and  its  Etiology  on  page21. 

Pathology. — Gonococcal  chronic  uretln-itis  is  never  primary  but 
always  secondary  to  one  or  more  acute  infections.  In  general  patho- 
genesis, like  the  acute  manifestations  of  this  infection,  the  anterior 
and  posterior  forms  differ  from  each  other  chieflj^  in  respect  to  theu' 


2GG  CHROXIC  URETHRITIS 

perniaiuMit  lesions.  The  essence  of  the  process  is  gonococcal  infection 
of  tlie  nuicosa,  with  or  without  coni])licatinij;  deposits,  in  the  ghuuls 
and  organs  hnniediately  associated  with  the  m*ethra.  The  inllannna- 
tion  is  of  two  forms:  (1)  chronic,  persistent  and  stationary;  and  (2) 
chronic  and  slowly  progressive.  Both  may  be  subject  to  exacerba- 
tions and  are  at  the  basis  either  of  sup})urative  and  catarrJuil  inflanuna- 
tions,  more  or  less  associated  in  the  marked  cases,  or  catarrhal  alone, 
after  the  su])pin'ation  has  subsided  in  the  milder  cases.  There  are, 
therefore,  cell  proliferation  in  the  deeper  layers  and  desquamation  of 
the  cylindrical  epithelium  in  the  superficial  layers,  with  a  tendency 
toward  recovery  and  substitution  of  squamous  for  cylindrical  cells. 
Thv  regeneration  may  ne^•er  be  complete,  so  that  a  kind  of  variable 
balance  is  present  betw-een  the  loss  and  the  restoration  of  the  lining 
cells.  This  same  type  of  process  is  present  whether  the  mucosa  is 
of  the  lu'cthra,  its  mucous  glands  and  the  prostate  in  the  male  or  of 
the  urethra,  ^'agina  and  uterus  in  the  female.  The  gonococci  become 
buried  in  the  depths  of  the  epitheliimi  along  the  m'cthra,  in  the  mucous 
cri^-pts  and  in  the  glands,  w-here  they  may  persist  for  years  without 
great  inconvenience  to  the  patient,  but  with  danger  of  infection  of  the 
opposite  sex. 

The  tissues  involved,  therefore,  are  the  mucosa  in  all  its  layers,  the 
submucosa  and  not  infrequently  tissues  beyond  this  structure,  and  all 
in  one  or  more  of  the  foregoing  processes.  To  these  should  be  added 
the  small  mucous  glands,  both  simple  and  compound,  and  such  out- 
lying structm-es  as  the  glands  of  Cowper,  the  prostate,  the  testicles, 
the  vasa  deferentia  and  the  like. 

The  temporary  lesions  are  found  only  in  the  catarrhal  forms,  from 
which  full  recovery  may  be  had,  whether  associated  with  the  chronic 
suppurative  foci  without  recovery  or  essentially  catarrhal  after  the 
suppm-ation  has  ceased.  They  are  tj^^ified  by  stratification,  infil- 
tration, desquamation,  superficial  ulceration  and  catarrhal  exudate. 
The  stages  are  stratification  of  the  cylindrical  epithelium  up  to  many 
layers,  even  a  half-dozen  wherever  the  mucosa  occurs  along  the 
lu-ethra  and  in  its  glands.  Then  the  other  processes  occm*  and  induce 
the  permanent  changes  in  the  same  distribution.  The  desquamation 
and  ulceration  become  deeper,  pavement  epithelium  replaces  the 
upper  layer  of  the  cylindrical  cells,  the  infiltration  augments  and  a 
certain  amount  of  dryness  and  elasticity  occurs,  resembling  the  skin 
and  possessing  decreased  permeative  and  absorptive  powers,  thus 
rendering  local  treatment  less  efficient.  Such  changes  of  cylindrical 
to  pavement  cells  probably  always  occurs  in  fully  established  severe 
disease,  with  true  chronic  termination.  The  mucous  glands  about 
such  a  focus  take  on  exaggerated  activity  in  compensation  for  the 
dryness  and  thus  lead  to  chronic  uninfecting  catarrhal  discharge, 
w^hich  may  never  be  corrected,  and  had,  in  fact,  best  be  left  untreated 
as  it  is  beneficial.  The  deeper  ulcers  and  infiltrations  may  result  in 
cicatrices  and  thickenings,  followed  by  retraction,  with  deformity  of 
the  course  and  caliber  of  the  urethra  or  in  exuberant  granulations 


GONOCOCCAL  CHRONIC  URETHRITIS  267 

and  polypi.  By  exactly  the  same  steps  the  mucosal  glands  are  altered, 
some  are  destroyed  and  others  hypertrophied  with  chronic  discharge. 
The  loss  of  mucosa  followed  by  cicatrix  and  infiltration,  and  then  by 
deformity  in  course  and  caliber,  is  the  basis  of  organic  stricture  of  the 
urethra. 

The  associated  lesions  are  chiefly  those  induced  by  the  organisms  of 
complicating  infections,  as  stated  in  the  discussion  of  Acute  Urethritis 
on  page  82,  or  those  of  the  diathesis  promoting  the  chronic  disease. 
The  complicating  lesions  are  those  of  the  organism  involved  in  this 
process,  too  numerous  for  full  discussion  when  one  bears  in  mind  that 
the  pathogenesis  is  identical  wherever  the  gonococcus  and  its  allies 
penetrate. 

In  the  pathology  of  the  anterior  urethra  special  glandular  structures 
require  attention  and  study. 

It  is  well  to  note  rather  fully  the  changes  in  the  glands  of  Morgagni 
and  Littre  which  occur  in  two  stages,  activity  and  destruction,  and 
the  lesions  of  the  periurethral  structures.  The  crypts  of  Morgagni 
during  the  stage  of  activity  enlarge,  hypertrophy  and  show  patulous 
ducts,  and  may  not  greatly  progress  beyond  these  points;  but  in 
the  stage  of  destruction  they  suffer  chronic  suppuration,  occlusion  and 
cyst  formation  and  may  even  lead  to  periurethral  abscess  and  fistulse. 
They  may  disappear  by  atrophy,  sclerosis  and  retraction.  The  glands 
of  Littre  may  suffer  similarly  by  the  prominent  processes  of  the  gono- 
coccal infection,  that  is  to  say,  substitution,  compression  and  occlu- 
sion. The  stage  of  substitution  is  as  in  the  urethral  epithelium,  that 
of  pavement  for  cylindrical  cells,  with  secondary  alteration  of  the 
glandular  secretion,  and  even  disappearance  of  the  cell  and  its  replace- 
ment by  round-cell  infiltration.  The  stage  of  compression  is  due  to 
intense  cellular  infiltration,  with  retraction,  contraction,  pressure 
and  slow  destruction  of  the  gland.  The  stage  of  occlusion  shows  the 
ducts  blocked,  the  contents  retained  to  form  simple  cysts  or  suppu- 
rating foci,  which  may  bm-st  into  the  urethra  or  the  cavity  of  the 
affected  organ  or  into  the  periurethral  tissues,  thus  forming  by  per- 
sistence or  repetition  of  the  process  sinuses,  abscesses  and  fistulse. 
Suppurating  occluded  glands,  after  rupture  and  discharge,  are  clinically 
the  most  dangerous  as  sources  of  infection.  The  gonococcus  lurks 
in  the  depths  of  the  glands,  in  the  lowered  focal  resistance  from  which 
for  anatomical  reasons  it  is  often  impossible  to  drive  it,  and  from 
which  it  may  proceed  to  a  fresh  outbreak  through  any  cause  favoring 
congestion  of  the  m*ethra,  such  as  excesses  in  food,  alcohol  and  sexual 
relation. 

The  periurethral  tissues  may  be  attacked,  especially  when  many 
acute  infections  have  been  grafted  on  each  other  without  cure  of  any 
or  when  improper  instrumentation  has  opened  up  the  mucosa  for 
penetration  into  the  outlying  structures.  Thus  the  corpus  spongio- 
sum urethrse  is  infiltrated  with  round  cells,  which  are  finally  replaced 
by  fibrous  tissue  which  contracts,  retracts  and  deforms  as  stricture,  or 
the  corpus  is  invaded  by  abscess  and  fistula. 


26S  CHROXIC  URETHRITIS 

The  foregoinc;  data  apjily  both  to  anterior  and  posterior  gonococcal 
chronic  m-ethritis.  but  a  t'e\\-  features  of  the  hitter  should  recei\-e 
individual  note. 

In  the  posterior  urethra  tiie  ])rocesses  are  infiltration,  proliferation 
and  desquaniation,  followed  by  repair  and  substitution.  The  infection 
has  a  great  tendency  to  reach  the  subepithelial  layers  and  to  penetrate 
the  glands  which  are  essentially  connected  with  the  posterior  ui-ethra. 

In  the  prostatic  urethra  the  ejaculatory  ducts  in  the  coUiculus  are 
by  the  tissue  changes  often  compressed,  distorted  and  strictured,  or 
contrariwise,  patulous  and  inflamed,  Avitli  chronic  discharge,  inviting 
or  suggesting  spermatorrhea.  The  prostatic  ducts  in  the  sinuses  of 
the  urethra  are  also  either  infiltrated  and  destroyed  or  chronically 
inflamed  with  plugs  of  mucopus  or  pus.  The  prostatic  acini  or  glands 
show  changes  duplicate  to  those  of  the  urethra  and  its  glands:  (1) 
The  lining  epitheliiun  may  be  predominately  affected,  desquamated 
and  finally  atrophied,  resulting  in  a  secretion  which  is  stringy,  abun- 
dant, opaque  and  filled  with  degenerated  epithelial  and  pus  cells;  or 
(2)  suppuration  may  be  the  chief  factor  and  determine  the  character 
of  the  discharge.     Thus  two  forms  of  chronic  prostatitis  are  produced. 

In  the  membranous  portion  between  the  layers  of  the  triangular 
ligament  there  are  no  glands  of  unportance,  but  the  infiltration, 
followed  by  the  inelasticity  and  acted  on  by  the  muscles,  not  infre- 
quently produces  more  or  less  splits,  tears  and  ulcers,  which  may 
be  the  basis  of  stricture. 

Granulumata  and  Fapillomata. — The  urethral  mucosa,  as  that  in 
all  other  parts  of  the  body,  when  subjected  to  chronic  inflammation 
shows  hj'pertrophy  of  various  elements  into  caruncles,  granulomata, 
papillomata  and  polj^ii.  The  granulomata  are  granulations,  as 
already  stated,  of  exuberant  character  on  unhealed  ulcers.  The  papil- 
lomata and  the  pol^'pi  may  be,  in  a  certain  sense,  later  sequels  of  the 
chronic  inflammation,  probably  as  in  the  nose  either  the  direct  result 
of  the  inflammation,  with  more  or  less  retention  of  secretions,  or  of 
changes  about  strictures,  especially  in  the  proximal  aspect  where  re- 
tention is  very  abundant.  These  lesions  have  been  studied  by  Burck- 
hardt,^  who  divides  them  into  caruncles,  condylomata,  papillomata 
and  mucous  and  glandular  polypi. 

Caruncles  occiu-  most  frequently  in  females  at  the  meatus  of  the 
urethra,  have  a  fiery,  raspberry-like  appearance,  a  sessile,  rather 
defined  attaclmient  and  a  tendency  to  bleed  on  contact,  through  great 
vascularity.  Their  microscopic  elements  are  numerous  dilated  blood- 
vessels in  a  mass  of  pavement  epithelium  in  layers.  To  contact 
with  urine,  the  finger  or  instrmnents  in  examination  and  the  penis  in 
coitus  they  are  usually  excruciatingly  painful. 

Granulomata  occur  more  frequently  in  males  in  the  posterior  urethra, 
particularly  the  prostatic  portion,  have  the  appearance  of  a  cock's 
comb  and  the  resemblance  to  the  condylomata  acuminata  seen  exter- 

iHandbuch  der  Urologie,   1906,  iii,  267. 


GONOCOCCAL  CHRONIC  URETHRITIS  200 

nally  under  the  foreskin  and  about  the  vulva.  Their  attachment  is 
usually  pedunculated,  with  hcip;ht  and  width  greater  than  the  base, 
or  less  frequently  sessile,  with  the  base  equal  to  or  greater  than  the 
other  dimensions.  Their  vascularity  is  rather  sparing.  The  micro- 
scopic elements  are  a  few  bloodvessels  in  a  more  or  less  fibrous  delicate 
stroma  surrounded  by  a  rather  thick  pavement-epitheliimi  covering 
in  layers. 

Papillomata  also  occur  more  frequently  in  males  and  in  the  posterior 
urethra.  In  appearance  they  resemble  the  foregoing  granulomata, 
adding  the  presence  of  definite  papilla?.  Their  attachment  is  also 
pedunculated  or  sessile.  Under  the  microscope  the  papillae  are  unmis- 
takable, with  a  thick  pavement  epithelial  covering  and  rich  blood- 
vessels extending  through  the  pedicle  and  its  various  papilla?. 

Mucous  polypi  and  glandular  polypi  occur  in  both  sexes  and  most 
frequently  around  the  neck  of  the  bladder,  although  they  are  found 
at  almost  any  point  of  the  urethra.  In  appearance  they  are  cystic 
and  translucent,  somewhat  resembling  a  white  grape,  and  in  attach- 
ment usually  pedunculated,  although  the  earlier  developments  may 
be  sessile.  In  microscopic  elements  they  are  probably  inclusion 
processes,  with  a  loose  soft-tissue  stroma  and  few  bloodvessels,  covered 
with  a  stratified  pavement  epithelium  containing  numerous  glands. 

Symptoms  in  General. — In  accordance  with  whether  the  disease  is 
of  the  anterior  or  the  posterior  urethra  the  symptoms  will  vary  and 
should  be  individually  discussed.  The  term  "anterior  urethra,"  as 
adopted  by  urologists,  means  the  luethra  distal  to  the  triangular 
ligament,  while  "posterior  m-ethra"  denotes  the  canal  proximal  to 
this  structure.  The  symptoms  are  subjective  and  objective,  local 
and  systemic.  In  the  nature  of  things  subjective  and  systemic  symp- 
toms are  relatively  much  less  than  objective  and  local,  inasmuch  as 
the  elements  of  discomfort  and  the  like  have  largely  disappeared  from 
the  subjective  local  conditions  and  inasmuch  as  that  of  absorption  is 
in  the  vast  majority  of  cases  without  complications  has  also  ceased 
and  with  it  the  subjective  systemic  signs.  Unlike  acute  urethritis, 
chronic  cannot  be  described  as  possessed  of  periods  of  incubation, 
invasion,  establishment  and  termination.  On  the  other  hand,  the 
acute  disease,  simply  without  definite  termination,  passes  into  the 
chronic  type  which,  as  previously  stated,  may  have  periods  of  quies- 
cent persistence,  of  progTcssing  exacerbations  and  finally  termination 
in  a  lifelong  catarrh  or  one  or  several  of  the  more  important  sequels. 
The  whole  progress  of  posterior  chronic  luethritis  is  usually  more  or 
less  marked  by  complications.  We  therefore  find  great  decrease  or 
even  disappearance  of  the  chief  local  s^Tuptoms  of  acute  iu:ethi'itis 
which  were  stated  as  discomfort,  pain,  pollakiuria,  hemorrhage,  exu- 
date and  chordee.  The  terminal  modifications  of  one  or  more  of  these 
symptoms  may,  however,  persist  until  cm-e  or  diuing  any  exacerbation 
of  the  process  reappear  more  or  less  in  its  entirety  as  an  acute  process. 

Anterior  Chronic  Urethritis.^ — Symptoms. — The  prevailing  sATuptom 
is  a  slight  persistent  discharge  manifesting  itself  in  four  ways,  each 


270  CHRONIC  URETHRITJS 

constitiitins:  a  type  of  case  more  or  less  distiiietly.  The  term  dis- 
charge should  be  most  carefully  defined,  as  any  abnormal  exudate  from 
the  m-ethral  walls,  fluid  and  copious  in  all  acute  and  in  some  chronic 
manifestations,  but  viscid  and  scanty  in  the  majority  of  chronic 
cases.  1'hus  the  term  means  an  exudate  whether  it  is  free  pus  or 
mucopus  in  the  early  periods,  or  -watery  moisture  or  jiiunmy  moisture, 
or  a  thick  dro])  at  the  meatus,  and  finally  merely  shreds  in  the  \u-ine. 
In  other  words,  it  is  any  departure  from  the  normal  urine  due  to  infec- 
tion and  characterized  by  the  presence  of  such  urethral  exudate  and 
elements  when  compared  with  their  absence  in  healthy  m"ine.  It  is 
well  to  have  patients  understand  this  view  of  discharge  in  order  to 
prevent  them  from  ceasing  treatment  when  the  free  copious  stage  is 
gone. 

In  anterior  chronic  urethritis  discharge  may  show  itself,  as  stated, 
in  four  ways: 

1.  A  drop  or  drops  of  greenish-white  or  yellowish  pus,  thic^k  in 
consistency,  appears  at  the  meatus  in  the  morning  on  rising  or  during 
the  day  at  stated  intervals  between  urinations.  It  seems  to  possess 
little  tendency  to  close  the  lips  of  the  meatus,  lies  free  in  the  cavity 
of  the  urethra,  is  highly  infectious,  and  usually  denotes  recent  chronic 
lesions  or  complications  or  both. 

2.  A  drop  of  mucopus  or  pus  appearing  chiefly  in  the  morning, 
with  much  tendency  to  gimi  the  lips  of  the  outlet  together.  This  is 
a  transitional  condition,  as  a  rule,  between  the  more  free  pus  of  the 
first  class  and  the  watery  mucous  condition  of  the  next  form. 

3.  A  watery  discharge,  chiefly  mucus,  most  abundant  on  stripping 
the  lu-ethra  and  without  much  tendency  to  giun  the  lips.  It  is  apt  to 
be  present  after  urination,  but  must  be  carefully  distinguished  from 
the  drop  of  lu^ine  sometimes  late  in  appearing  after  this  act.  It  is 
also  to  be  distinguished  from  the  mucous  moistm'c  induced  by  sexual 
excitement  and  sometimes  by  pressure  upon  the  prostate  of  consti- 
pated movements.  It  must,  in  other  words,  be  of  strictly  post- 
inflammatory lu-ethral  origin. 

4.  Shreds  alone  in  the  lU'ine  without  subjective  and  often  without 
objective  sign  at  the  meatus,  but  constituting,  nevertheless,  discharge 
in  the  sense  designated  above. 

Exactly  as  the  sputmn  in  tuberculosis  carries  the  Bacillus  tubercu- 
losis, any  and  all  these  forms  of  discharge  are  commonly  the  means  of 
carrying  the  gonococcus,  and  should,  therefore,  in  every  case,  be 
carefully  searched  for  the  organism  before  adopting  a  policy  of  treat- 
ment or  uttering  a  prognosis.  The  patients  should  receive  very  careful 
instructions  as  to  the  infectiousness  of  all  these  forms  of  urethral 
discharge. 

It  is  probable  that  a  persistent  single  drop  is  commonly  the  sign  of 
anterior  chronic  urethritis,  for  the  reasons  that  so  small  an  exudate 
from  the  posterior  urethra  cannot  during  the  night  gravitate  forward 
past  the  triangular  ligament,  the  pocket  of  the  bulb,  and  finally  the 
angle  where  the  penile  urethra  folds  itself  over  the  scrotum.     If  the 


GONOCOCCAL  CHRONIC  URETHRITIS  271 

discharge  in  drops  is  more  copious  it  may  come  from  either  the  ante- 
rior or  the  posterior  or  the  anteroposterior  urethra.  Careful  physical 
examination  including  proper  urinary  specimens  will  indicate  and 
urethroscopy  decide.  The  influence  of  the  anatomy  of  the  bulb  on 
urethral  discharge  should  be  recognized. 

The  bulb  of  the  anterior  urethra  may  often  be  the  chief  point  of 
chronic  disease,  owing  to  its  anatomical  conditions  and  variations. 
It  may  be  deep  or  shallow,  long  or  short,  with  many  or  few,  simple  or 
complex  folds  of  its  mucosa  over  the  bulbocavernosus  muscle,  so  that 
in  the  urethroscope  it  resembles  a  urinary  bladder  in  miniature  imper- 
fectly dilated.  Its  mucous  crypts  and  glands  are  numerous  and  with 
the  ducts  of  Cowper's  glands,  if  infected,  add  to  the  difficulty.  Dis- 
charge may  pocket  in  the  bulb  and  scarcely  show  at  the  meatus  during 
the  day  if  scanty,  but  otherwise  if  more  copious,  and  moreover,  diurnal 
urination  every  two  or  three  hours  flushes  out  the  urethra  so  that 
frequently  the  discharge  cannot  accumulate  and  appear. 

The  genesis  of  the  morning  drop  is,  therefore,  that  during  the  hours 
of  sleep  the  discharge  accumulates,  gravitates  forward  to  the  meatus, 
where  in  the  fossa  navicularis  and  behind  the  apposed  lips  of  the 
meatus  it  is  retained  and  dried  into  a  small  scab  comprising  that 
minute  quantity  of  it  which  appears  in  the  cleft  of  the  meatus.  The 
fold  of  the  penile  urethra  at  the  scrotum  tends  to  determine  that  most 
of  the  discharge,  unless  copious,  seen  at  the  meatus  is  from  the  ante- 
rior urethra,  but  such  a  distinction  is  not  safe,  except  in  the  presence 
of  one  of  the  multiple  glass  tests,  of  which,  in  the  opinion  of  the  -^Titer, 
none  is  better  than  the  five-glass  test  of  Wolbarst,  which  the  writer 
carries  out  in  a  special  manner  and  adapts  to  cases  of  anterior  and 
posterior  chronic  urethritis  without  complications  in  the  prostate  or 
seminal  vesicles,  because  such  complications  require  as  far  as  possible 
separation  of  discharge  from  the  prostate  and  the  vesicles  from  each 
other  as  three  separate  specimens.  Such  distinction  is  afforded  by  the 
seven-glass  test  of  the  author,  which  is  fully  described  in  Chapter 
VIII  on  General  Principles  of  Diagnosis  on  page  455,  and  need  not 
be  repeated  here.  The  steps  of  the  author's  technic  of  the  Wolbarst 
fiA-e-glass  test  are  as  follows: 

The  meatus  is  washed  and  a  No.  12  French  rubber  or  lisle-thread 
catheter  is  passed  to  the  bulb  of  the  urethra  and  stopped  at  the  tri- 
angular ligament.  Experience  shows  how  to  recognize  this  point  by  slight 
resistance  to  the  catheter.  With  a  hand  syringe  150  c.c.  of  hot  normal 
salt  solution  are  flushed  through  the  urethra  from  behind  forward  into 
a  sterilized  glass  which  is  known  as  Glass  I,  or  the  Anterior  Urethral 
Glass,  Massage  of  the  urethra  before  introducing  the  catheter  loosens 
adherent  shreds  and  makes  the  irrigation  more  efficient. 

The  uretlira  is  now  gently  massaged  from  the  bulb  forward  and  the 
same  step  repeated,  which  gives  Glass  II  or  the  Control  Anterior 
Urethral  Glass.  The  piupose  of  the  massage  is  to  dislodge  discharge 
adlierent  to  the  urethra  but  not  washed  off  by  the  first  test.  If  the 
disease  is  in  the  anterior  urethra  alone,  practically  all  its  products 


-,2  CllliOXIC  URETHRITIS 

Avill  be  in  Glass  I  and  very  few  in  Glass  IT,  and  tliey  will  conforni  with 
each  other  more  or  less  definitely  in  kind  and  condition.  If  the 
control  anterior  urethral  i:;lass  contains  much  exudate,  another  wash- 
ing of  the  anterior  urethra  may  be  given  in  order  to  insure  against 
error  and  this  glass  may  be  mixed  with  Glass  II  or  held  as  Glass  Il-a. 
Such  an  extra  glass  is  of  great  service  in  coin]ileting  the  diagnosis  of 
the  anterior  urethra. 

The  patient,  who  should  be  instructed  to  hold  his  urine  before  the 
test  for  at  least  i\\e  hours,  with  the  double  ]nu-]iose  of  permitting  ])lenty 
of  discharge  to  acciunulate  in  the  m-ethra,  and  of  urine  in  the  bladder, 
now  passes  one  glass  of  urine.  This  is  known  as  (ilass  III,  or  the  Pos- 
terior Urethral  (ilass,  as  it  will  necessarily  contain  exudate  from  the 
posterior  urethra.  Glasses  I,  II,  III  will  show  rather  conclusively 
that  the  disease  is  anterior,  posterior  or  both  in  its  situation.  Further- 
more, the  differences  in  the  character  of  the  discharge  in  Glass  III, 
when  com])arcd  with  its  i)redecessors,  are  diagnostic  and  should  be 
noted.  The  shreds  of  the  posterior  m'ethra  are  apt  to  be  long,  large 
and  lumpy,  while  those  of  the  posterior  urethra  are  shorter,  smaller 
and  filamentous. 

A  small  (No.  10  Fr.)  catheter  is  now  passed  into  the  bladder  with 
great  gentleness  and  thus  Glass  IV,  or  the  Bladder  Glass,  is  obtained, 
and  if  clear  will  show  that  the  bladder,  m-eters  and  kidneys  are  not 
involved,  but  if  piu-ulent  will  indicate  the  reA^erse  possibility  and  the 
necessity  for  exploration  of  the  m"inary  as  well  as  the  sexual  organs. 
A  small  soft  catheter  and  great  gentleness  are  advisable  in  order  to 
ehminate  any  great  danger  of  tramnatism  or  pressure  M'hich  might 
produce  the  sudden  discharge  of  the  glands  into  the  urethra. 

IMassage  of  the  prostate  and  seminal  vesicles  is  now  performed  in 
vigorous  but  judicious  fashion,  and  then  the  patient  empties  his  bladder 
into  one  or  more  glasses,  thus  producing  Glass  V,  or  the  Massage  Glass, 
having  in  it  the  products  of  infection  in  the  organs  named.  If  on 
arrival  the  patient  has  not  much  lu-ine  in  his  bladder,  while  the  cath- 
eter is  in  place  for  Glass  IV,  warm  sterile  normal  salt  solution  should 
be  passed  into  the  bladder  so  as  to  give  artificial  means  of  securing 
the  massage  specimen.  It  will  be  noted  that  the  IMassage  Glass  con- 
tains a  mixture  of  the  exudate  from  the  prostate  and  the  right  and 
left  seminal  vesicles.  If  purulent  material  or  detritus  is  found  in  this 
glass  it  is  almost  impossible  to  tell  whether  it  comes  from  the  prostate 
and  both  vesicles  in  association  or  from  only  one  or  from  any  two  of 
these  three  organs.  The  seven-glass  test  of  the  author  largely  removes 
this  difficulty  by  giving  the  contents  of  the  prostate  in  Glass  V  and 
those  of  the  right  and  left  seminal  vesicles  in  Glass  VI  and  Glass  VII, 
as  fully  described  in  the  subject  of  diagnosis. 

As  a  preventive  against  infection  it  is  well  to  give  m-inary  antiseptics 
for  a  day  or  two  before  and  after  such  an  investigation. 

The  original  Thompson  two-glass  test  is  not  sufficient  for  a  distinc- 
tion between  anterior  and  posterior  chronic  urethritis — a  fact  which 
necessitates  the  adoption  of  the  Wolbarst  or  other  multiple-glass  test, 


GONOCOCCAL  CHRONIC  URETHRITIS  273 

as  previously  discussed.  After  study  of  the  results  of  multiple-glass 
tests  the  course  of  the  case  may  be  readily  followed  by  the  two-glass 
method  with  regard  to  the  amount  of  pus  and  the  number,  character 
and  density  of  the  filaments,  combined  with  frequent  microscopic 
investigation  of  the  latter.  At  any  moment  the  five-glass  test  may 
be  repeated  in  settlement  of  any  question  of  doubt,  but  always  with 
the  aid  of  posterior  and  anterior  urethroscopy. 

It  must  not  be  forgotten  that  chronic  discharge  in  the  anterior 
urethra  is  often  due  to  infection  of  the  mucous  crypts  throughout 
the  canal,  and  of  Cowper's  glands  in  the  bulb.  Follicular  chronic 
urethritis  and  chronic  cowperitis  are  really  complications  of  anterior 
chronic  urethritis,  exactly  as  their  acute  lesions  are  complications  of 
anterior  acute  disease;  and  will  therefore  be  treated  under  that 
heading. 

Diagnosis. — ^This  is  determined  on  the  factors  fully  discussed  in 
Chapter  VIII  on  General  Principles  of  Diagnosis  on  page  428. 

The  history  shows  the  acute  attack  with  severe  and  prolonged 
symptoms  and  sometimes  improper  and  violent  treatment.  These  . 
are  followed  by  the  symptoms  of  the  characteristic  persistent  drop 
containing  pus,  watery  moisture,  gumminess  or  a  thick  mass  crusting 
at  the  meatus  and  the  physical  examination  verifies  the  existence  of 
the  drop  and  studies  the  characteristics  of  the  shreds  in  the  urine. 
In  the  Thompson  two-glass  test  in  mild  cases  the  first  glass  alone 
may  show  pus  or  shreds  but  in  severe  cases  these  elements  are  in  both 
glasses.  For  this  reason  the  author's  seven-glass  test  is  to  be  pre- 
ferred in  that  it  distinguishes  the  contents  of  the  anterior  urethra  from 
those  of  the  posterior  urethra  and  from  those  of  the  annexa.  In 
anterior  chronic  urethritis  the  Anterior  Urethral  Glass  will  contain 
the  contents  of  the  canal  and  the  Control  Glass  little  or  nothing.  All 
other  glasses  are  negative.  The  laboratory  recognizes  the  gonococcus 
in  the  drop  or  shreds  and  the  treatment  verifies  the  other  findings. 

Treatment. — Before  the  treatment  of  gonococcal  chronic  urethritis 
may  be  instituted,  certain  general  principles  must  be  laid  dowTi  and 
understood.  They  apply  to  the  subject  as  a  whole  independently  of 
whether  or  not  the  disease  is  in  the  anterior  urethra  or  posterior 
urethra  in  its  chief  lesions. 

The  preventive  and  abortive  treatment  are  self  evidently  possible 
only  in  the  proper  management  and  gentle  treatment  of  every  case  in 
prevention  with  strict  cooperation  on  the  part  of  the  patient.  It  is 
well  known  that  severe  acute  infections  invariably  have  a  chronic 
'  stage  which  is  increased  in  intensity  and  duration  by  WTong  treatment. 
Complicated  cases  are  rather  essentially  chronic  in  their  termina- 
tion as  suitably  detailed  in  Chapter  V.  Patients  who  debauch  in 
food,  drink  and  sexuality  during  treatment  invite  and  induce  chronic 
lesions  as  well  as  reinfections  grafted  on  nearly  cured  conditions.  Any 
infection  which  has  persisted  for  about  four  months  may  be  regarded 
as  chronic.  Abortive  measures  in  the  exact  sense  do  not  exist  for  the 
posterior  urethra. 
18 


274  CHRONIC  URETHRITIS 

Citratiir  7'/7Yj//??g/?/.— Intelligent  application  of  suitable  measures 
cannot  be  carried  out  ■without  just  knowledge  of  the  needs  of  each 
case  as  embotlied  in  the  indication. 

Methods  of  treatment  are,  as  before,  two:  (1)  The  conservative 
or  expectant,  and  (2)  the  irrigation,  both  of  whose  main  features  in 
technic  are  the  following,  varying  with  anterior  and  posterior  urethral 
involvement . 

Management  is  the  same  for  both  methods  of  treatment  of  each 
portion  of  the  canal  and  will  not  be  again  noted.  Cooperation  and 
obedience  by  the  patient  are  essential.  The  tendency  of  the  patient 
to  depreciation  and  discouragement  indicates  hygiene  in  fresh  air  and 
all  effort  to  a^■oid  nervous  unrest  and  indigestion  with  secondary 
phosphaturia.  Rest  in  the  sexual  sense  forbids  intercourse  during 
regidar  treatment  and  restricts  indulgence  for  a  period  after  treat- 
ment has  ceased,  in  order  to  avoid  the  congestion  which  excites  inflam- 
mation and  relapse.  Indirect  sexual  excitement  is  very  undesirable. 
Care  sunilar  to  that  in  chordee  will  avoid  seminal  emissions.  Bodily 
rest  permits  exercise  wdthout  exhaustion  or  congestion  of  the  parts, 
but  these  restrictions  are  less  definite  than  in  acute  disease.  No 
exercise  with  vibration  or  great  distiubance  is  advisable  and  the 
moderate  forms,  such  as  walking,  are  best.  Hygiene  must  secure 
absence  from  the  cause  of  catarrhal  inflammation.  Therefore  alcohol 
and  improper  diet  are  interdicted.  Regular  habits  of  life  and  exercise 
avoid  dissipation  of  the  general  health,  strength  and  resistance. 
Patients  with  known  dyscrasine  should  receive  attention  for  them. 
Diet  and  drinks  should  be  moderate  and  normal,  of  the  nonirritating 
and  nonconstipating  tjT^es.  No  alcohol  or  highly  spiced  stimulating 
mixtures  are  allowed. 

There  are,  therefore,  required  relief  of  the  chronic  urethral  dis- 
charge, control  of  the  urinary  disturbance,  quiescence  of  sexual  dis- 
order and  prevention  of  complications  and  sequels.  One  sees  three 
general  classes  of  cases:  (1)  Intermittent  discharge,  which  is  absent 
during  the  use  of  hand  injections  and  restrained  habits  of  life,  but 
present  during  cessation  of  home  treatment  and  indulgence  in  im- 
proprieties in  alcohol,  food  and  sexual  relations;  (2)  continuous  dis- 
charge, which  slowdy  improves  under  treatment  and  usually  occurs 
with  anteroposterior  lesions;  (3)  shreds  which  may  be  large  or  small, 
long  or  short,  light  or  heavy  and  contain  chiefly  pus  or  little  pus 
mingled  with  mucus  and  detritus,  or  practically  pure  mucus  wdth  or 
without  much  epithelia.  A  careful  distinction  of  the  bacteriology  and 
source  of  all  three  forms  of  exudate  is  necessary  and  readily  performed 
with  the  aid  of  the  author's  seven-glass  test  as  noted  under  diagnosis. 

The  physical  measures  include  massage,  hydrothera])y  and  electro- 
therapy. ^Massage  is  advisable  only  several  weeks  after  ac'ti\'e  symp- 
toms and  is  of  little  avail  unless  performed  with  an  instrmnent  in 
situ,  such  as  a  soft,  lead-core  dilator,  a  straight  or  standard  urethral 
sound  or  preferably  a  Bangs  syringe  sound,  because  the  massage  and 
instillation  may  be  combined  at  the  one  sitting.     Its  object  is  to 


GONOCOCCAL  CHRONIC  URETHRITIS 


275 


Tig.  64. — Passing  a  straight  sound.  "Gravitation"  is  the  only  step.  The  penis  is 
held  vertically  in  the  left  hand  behind  the  glans  while  the  lubricated  instrument  is 
allowed  to  fall  of  its  own  weight  as  far  as  the  bulb  with,  only  support  in  the  vertical 
position  by  the  right  hand  of  the  urologist.     (Original.) 


Fig.  65. — Massage  of  chronic  folliculitis.  The  left  hand  supports  the  urethra  on  the 
stretch,  over  the  straight  sound,  wliich  reaches  the  bulb.  The  right  hand  massages  the 
urethra  and  its  follicles  along  the  instrument.     (Original.) 


276 


CHRONIC  URETHRITIS 


stimulate  erosions,  ulcerations  and  <;ranulations,  to  dissipate  soft 
erosions  and  to  evacuate  mucous  cry])ts — all  ^vith  gentleness  and 
without  secondary  reaction  and  as  preliminary  of  the  instillation  or 
as  alternate  Avith  it  e\ery  five  to  seven  days.  Progressive  benefit 
must  follow  this  treatment  as  well  as  other  measures  or  be  abandoned. 
The  instrmuent — dilator,  straight  or  standard  soiuid,  or  Bangs 's  syringe 
sound — is  passed  to  the  bulb  of  the  urethra  ascertained  with  the 
finger  on  the  perineinu.  Gravity  is  the  only  force  in  passing  these 
instnmients.  The  urethra  is  held  on  the  stretch  and  the  massage  is 
gently  performed  along  its  coiu-se  upon  the  shaft  of  the  instrument. 
No  pain  or  unfaAorable  reaction  should  occur  but  only  stimulation  of 
the  indolent  nuicosa.     ^lassage  of  the  lu-ethra  may  also  be  performed 


Fig.  66. — Catheter  instillation,  supine  posture.  The  Wolbarst  basin  is  placed,  the 
penis  draped,  the  catheter  passed  and  the  instillation  administered  while  the  forceps 
holds  the  catheter  under  gauze  against  displacement  and  spatter.     (Original.) 


with  a  bougie-a-boule — always  the  flexible,  never  the  rigid  type  of 
instrimient — which  is  passed  into  the  canal  and  repeatedly,  rapidly 
but  gently  manipulated  back  and  forth  from  meatus  to  bulb.  Its 
size  must  not  overstretch  the  canal. 

Hydrotherapy  is  of  great  value  in  allaying  irritation,  especially  of 
overtreatment — instrumental,  chemical,  thermal  or  electrical.  Heat 
or  cold,  according  to  tolerance  and  response,  may  be  applied  to  the 
penis  externally  best  in  the  form  of  baths  in  a  large  mug  or  to  the 
urethra  internally  preferably  by  means  of  the  syringe-and-catheter 
irrigations,  as  these  are  safest  and  gentlest.  A  straight  urethral 
sound  chilled  in  ice-water  may  be  passed  into  the  urethra  and  left  there 
for  five  to  ten  minutes,  every  five  to  seven  days,  associated  with  other 


GONOCOCCAL  CHRONIC  URETHRITIS 


277 


measures,  if  found  beneficial.  Hydrotherapy,  except  through  its  heat 
or  cold  in  irrigations  and  instillations,  is  not  of  great  value.  In  the 
deeper  inflammation,  hot  sitting  baths  for  twenty  to  thirty  minutes 
until  the  skin  is  red,  followed  by  immediate  rest  in  bed,  are  good,  but 
must  be  repeated  at  least  night  and  morning.  Hot  or  cold  rectal  irri- 
gations through  the  double-current  instrument  of  Kemp,  or  with  two 
rubber  rectal  tubes  passed,  one  for  several  inches  into  the  bowel  and 
the  other  just  within  the  sphincter  beside  it,  give  relief.  Normal 
salt  solution  is  best,  and  is  hot  or  cold,  according  to  preference  and 
tolerance  of  the  patient  and  results. 


Fig.  67. — Various  types  of  urethral  sound.  From  above  downward  are  the  olive 
point,  lead-core,  woven,  lisle-thread  dUator;  the  straight  anterior  urethral  sound;  the 
Chetwood  double-taper  standard  sound ;  the  author's  short  beak  double-taper  irrigating 
sound  with  obturator  in  the  canal;  the  author's  standard  beak  double-taper  irrigating 
sound  with  the  obturator  below  it;  the  author's  short  beak  tunnelled  and  grooved  irri- 
gating sound  with  the  obturator  in  situ  and  the  standard  blunt  point  Benique  sound. 
(Original.) 


The  heliotherapy  fulfils  the  same  functions  as  hot-water  treatment 
and  decongests  the  parts.  It  is  applied  with  the  standard  therapeutic 
lamp  two  or  three  times  a  day  for  half-hoiu-  sittings  until  the  skin  is 
distinctly  redder,  as  with  a  poultice,  and  the  comfort  of  the  patient 
promoted.  It  is  of  more  service  in  deep-seated  posterior  urethritis 
and  its  complications,  notably  prostatitis  and  seminal  vesiculitis, 
under  which  heading  it  is  more  fully  discussed.  The  medicmal  supplies 
are  zinc  chloride  and  copper  sulphate  solutions  from  2  to  5  per  cent. 


27S 


( •llh'OXIC  VRF/rH  RITIS 


Tlie  fleet  rot  luM'a])y  is  i-itlier  loeal  or  systemic.  T/Oenl  measures  are 
ai)i)lie(l  throuj;li  tlie  urethra  or  the  reetum  for  germicidal,  inhibitory 
and  restorative  elleets,  and  systt^mie  tri'atment  to  the  hody  at  large 


Fig.  6S. 


-Portable  therapeutic  lamp,  efficient,  convenient  and  serviceable,  consisting 
of  parabolic  mirror  and  60  c.p.  lamp. 


for  its  stimulating  action.  The  forms  of  current  and  the  apparatus 
for  developing  and  applying  them  advised  by  expert  electrotherapeu- 
tists  are  the  following,  bearing  in  mind  that  much  electrical  equipment 


Fig.  69. — Metal  and  glass  rectal  electrodes.  From  above  downward  are  the  metal 
tipped  hard  rubber  handle  electrodes,  respectively  called  elongated  olive  rectal  electrode, 
elongated  olive  with  flat  face,  seminal  vesicular  electrode,  spoon-shaped  prostatic  elec- 
trode, hard  rubber  with  metal  face  prostatic  electrode.  Then  come  the  spoon-shaped 
x-ray  vacuum  high-tension  glass  prostatic  electrode  and  the  cone  pointed  instrument 
of  the  same  type. 

on  the  market  is  so  inefficient  as  to  be  toys.  Failure  with  such  outfits 
rests  with  the  defects  of  apparatus  and  with  the  inexperience  of  the 
operator. 


GONOCOCCAL  CHRONIC  URETHRITIS 


279 


The  equipment  comprises  machines  and  electrodes  with  accessories 
and  medicinal  supplies.  The  machines  are  of  five  types,  developing 
galvanic,  faradic,  sinusoidal,  static  and  diathermic  (true  high-fre- 
quency current  of  d'Arsonval)  currents,  l^^lectrodcs  arc  designed  for 
the  anterior  and  posterior  urethra  and  the  rectum.  The  anterior 
urethral  instruments  are  of  metal  or  glass.  The  metal  type  must  be 
properly  constructed  and  fully  insulated,  zinc  or  copper  tipped,  as 
shown  in  Fig.  70,  and  paragraphs  on  Electrolysis  of  Stricture.  The 
glass  type  are  fully  insulated,  high-vacuum  (for  localizing  effect) 
instruments,  as  shown  in  Fig.  09.  Posterior  urethral  electrodes  are 
also  of  metal  or  glass.  The  metal  forms  are  preferred  and  are  curved 
instruments,  with  metal  tips  1  to  2|  inches  long,  of  zinc,  copper,  alumi- 
num or  silver.  The  glass  type  must  also  be  curved,  and  are  shown 
in  Fig.  69.    Rectal  electrodes  are  made  of  metal  or  glass  and  the 


Fig.  70. — A  and  B,  short  and  long  curve  sounds;  C,  long  curve  bougie-a-boule  and 
C",  conical  points  for  the  same;  D,  semicurve  bougie-S,-boule  and  D',  long  cylindrical 
points  for  it;  E,  straight  bougie-&,-boule  and  E',  short  cylindrical  points  for  the  same. 

former  are  by  choice  the  elongated  olive  metal-tip  instrument  or  the 
flattened  olive  (spoon-shaped)  metal-tip  electrode  or  the  elongated 
olive  hard-rubber  instrument  with  a  metal  face.  Glass  is  made  up  into 
the  vacuum,  fully  insulated  electrode,  with  flattened  olive  tip  and 
exhausted  to  the  .r-ray  vacuum  degree  or  into  the  same  type  of  instru- 
ment with  a  conical  tip.  Of  the  two  terminals  used,  one  is  the  active 
electrode,  which  may  be  attached  to  either  the  positive  or  the  nega- 
tive pole,  according  to  indications,  and  the  other  is  the  indifferent 
electrode,  most  advantageously  made  of  a  gauze  or  sponge  covered 
pad  5  by  8  inches.  To  ensure  good  contact  it  is  moistened  with  warm 
water. 

The  selection  of  case  is  very  important.  Acute  urethritis  contra- 
indicates  electrotherapy  until  the  subacute  and  declining  stages  are 
initiated,  except  perhaps  diathermic  measures,  as  stated  later.   Clironic 


2S0  CHRONIC  URETHRITIS 

manifestations  invite  this  treatment,  which  is  independent  of  idio- 
syncrasy. Clironic  urethritis  without  infection  and  with  the  ordinary 
lesions  present,  such  as  erosions,  ulcerations  and  soft  infiltrations, 
requires  the  cataphoresis  of  galvanism.  Chronic  urethritis  with  infec- 
tion, nongonococcal  or  gonococcal,  and  any  of  the  foregoing  sequels 
indicates  cataphoresis  su]i]ileniented  with  the  high-potential  \'aeiunn 
electrodes. 

Diathermy  is  a  newer  doveli)])ment  of  ap])lying  the  true  high- 
frequency  (d'Arsonval)  cm-rent  locally  for  raising  the  temperature 
of  the  organs  by  closely  wrapping  them  with  malleable  metal  elec- 
trodes, because  imperfect  contact  produces  sparks  and  blisters.  The 
final  results  of  diathermy  in  acute  cases  are  still  sub  jiuJice,  but  the 
subject  should  be  mentioned  here.  General  depression  of  health  in 
indigestion,  nervousness  and  imperfect  elimination  indicates  stimulat- 
ing measures,  as  discussed  under  systemic  application  below. 

The  piu"poses  are,  therefore,  germicidal,  penetration  of  medication, 
astringency  and  tissue  massage,  and  each  recpiires  particular  applica- 
tion through  combination  of  machine,  current  and  electrode. 

The  local  application  is  urethral  or  rectal  or  both.  The  direct  or 
galvanic  current  from  the  street  mains  or  from  a  large  nimiber  of 
batteries  (both  with  j^roper  controlling  device  and  a  reliable  volt- 
meter and  ammeter),  is  used  in  the  anterior  urethra  with  the  metal- 
tipped  electrodes  described.  By  cataphoresis  it  deposits  in  the  tissues 
oxychlorid  of  the  metal  tips  employed  so  that  the  electrode  is  mildly 
consumed.  This  action  is  both  germicidal  and  powerfully  astringent. 
The  electrode  from  the  positive  pole  is  passed  into  the  urethra  up  to 
the  affected  points  and  the  indifferent  negative  electrode  is  fixed  on 
the  abdomen  or  the  back  low  down.  The  amount  of  current  is  3  to 
5  milliamperes  and  no  more.  Any  metal  astringent  previously  named 
under  equipment  may  be  soaked  into  several  layers  of  cotton  or  gauze 
wrapped  about  the  metal  tip,  but  if  iodin  is  selected  the  electrode 
must  have  a  carbon  tip  and  the  negative  pole  must  be  within  the 
urethra.  The  cataphoresis  produces  deep  penetration.  The  iodin  is 
dissolved  in  water  from  1  in  10  to  1  in  4  parts  and  the  application 
persists  for  five  to  ten  minutes  and  is  repeated  every  five  days.  Intense 
actinic  or  germicidal  and  mild  roentgen-ray  effects  are  produced  by 
the  insulated  high-vacuum  electrodes  of  glass  energized  from  the  nega- 
tive side  of  a  high-speed  static  machine,  while  the  positive  side  is 
grounded. 

The  tube  is  applied  at  the  affected  points  of  the  urethra  in  turn,  and 
intensity  is  measured  by  a  spark  gap  of  from  ^  to  1  inch  and  0.5  to  1 
milliampere  of  current  on  a  reliable  meter  in  series,  with  the  negative 
side  of  the  machine.  Two  to  five  minutes  are  the  limit  of  duration, 
and  one  visit  every  five  days  is  the  frequency,  with  longer  intervals 
as  improvement  occurs,  but  without  change  in  the  intensity  and  dura- 
tion of  the  treatments.  The  results  should  never  be  painful  and  with 
reaction  of  importance.    There  is  no  aftertreatment. 

The  systemic  application,  on  the  same  or  different  days  as  the  local 


GONOCOCCAL  CHRONIC  VRMTIIRITIH,  281 

treatment,  will  benefit  the  digestive,  nervous  and  eliminating  functions. 
The  digestive  system,  for  poor  assimiljitioii  urid  constipation,  requires 
the  combined  galvanic  and  faradic  siniis(M<lal  current  applied  with  a 
large  sponge  electrode  over  the  abdomen  and  another  between  the 
shoulders.  The  interruptions  of  the  faradic  current  must  be  thirty 
to  the  second  and  no  more,  in  strict  correspondence  with  normal 
muscular  fibrillation,  and  the  sine  wave  must  be  ahtiolvtehj  synchro- 
nous with  the  heart  impulse  in  order  to  aid  and  not  impede  circulation. 
Treatments  continue  for  from  ten  to  twenty  minutes,  every  other  day 
or  two  days,  and  always  short  of  weariness.  The  intensity  of  the 
current  should  not  cause  pain  or  discomfort,  and  must  leave  the  patient 
feeling  stimulated  and  not  exhausted.  Cutaneous  and  renal  elimina- 
tion are  increased  by  the  d'Arsonval  high-frequency  current,  employed 
by  the  autocondensation  method.  For  the  details  of  this  procedure 
the  reader  is  referred  to  recent  publications  by  Snow,^  Sinclair  Tousey,^ 
de  Kraft,^  Titus*  and  Steele^  because  they  are  too  minute  and  extensive 
for  inclusion  here. 

The  nervous  system  is  relaxed  and  relieved  of  tension  by  the  static 
wave  current  up  to  toleration,  and  comfort  applied  to  the  spine  for 
twenty  minutes  every  day  for  three  days,  and  then  every  two  or  three 
days  following  the  indications  of  improvement.  Under  this  treatment 
the  patient  should  leave  rested  and  restored  and  not  excited  or  wearied. 
The  electrode  is  always  attached  to  the  positive  pole  in  these  systemic 
treatments.  The  circulation  is  influenced  along  with  the  various  other 
systems  as  just  described  either  directly  or  indirectly,  and  needs  no 
further  comment. 

Medicinal  measures  are  of  least  value  by  internal  administration. 
Digestants,  good  hygiene,  hematinics  and  neurotonics  all  aid  the 
general  depression  and  absorption,  while  variations  in  the  blennor- 
rhetics,  urinary  antiseptics  and  urinary  diluents  have  their  own,  but 
after  all  little,  value.  Nothing  to  irritate  either  the  luethral  mucosa 
or  the  sexual  centers  through  the  urine  should  be  given.  Sedatives 
are  called  for  by  sexual  hj^Deresthesia.  The  drugs  are  much  the  same 
as  those  employed  in  the  acute  stages,  but  act  mostly  as  corrigents 
of  reaction  after  local  treatment  and  as  preventives  of  relapse.  The 
alkalis  dilute  and  neutralize  the  urine  and  avoid  irritation  of  the 
mucous  membrane.  They  are  the  alkaline  mineral  waters  and  the 
various  preparations  of  soda  and  potash.  The  balsams  and  oils  stimu- 
late the  mucous  membrane  and  improve  its  secretion  in  the  indolent 
catarrhs.  Urinary  antiseptics  prevent  the  transit  of  the  infection  from 
the  urethra  into  the  bladder  and  should  always  be  used  when  the 

1  Joiir.  of  Advanced  Therap.,  June,  1909;  Med.  Rec,  December  16,  1911;  Ibid., 
November  6,  1915. 

2  New  York  Med.  Jom-.,  May  22,  1909;  New  York  State  Jour.  Med.,  June,  1911. 

3  New  York  Med.  Jour.,  February  8,  1913;  23d  Annual  Meeting  of  the  American 
Electro  Therapeutic  Association,  September  2,  3  and  4,  1913;  and  the  same,  Jour,  of 
Advanced  Therap.,  October,  1914,  and  the  same,  Am.  Jour.  Electrotherap.  and  Radiol., 
January  and  February,  1916. 

4  New  York  State  Jour.  Med.,  July,  1912.  ^  Med.  Rec,  March  11,  1916,  p.  459. 


282  CIIROXIC  VRETHRITIS 

existence  of  tlie  sjonoeocei  is  known  or  suspected  during  instrumentation 
which  penetrates  the  l)lad(ler. 

Seriuntherapy  is  a\ailal)le  only  in  complicated  cases  or  profound 
infections  with  absorption.  The  selection  of  the  ])ro])er  case  and  the 
application  of  this  method  to  it  are  (liscusse<l  in  ('hai)ters  VIII  and 
IX  under  Serumdiagnosis  and  Serumtlierapy  on  pages  475  and  512. 

Local  administration  consists  of  (1)  hand  injections,  (2)  irrigations, 
(3)  retrojections.  (4)  instillations  and  (5)  api)lications.  Mild  hot 
astringents,  as  hand  injections,  usually  alternating  with  weak  anti- 
septics, such  as  the  newer  silver  salts,  argyrol  'A  to  5  per  cent.,  and 
protargol  0.25  to  0.5  per  cent.,  or  potassiiun  permanganate  1  in  8000 
and  silver  nitrate  1  in  10,000,  are  used. 

As  a  rule,  home  treatment  by  the  i)aticnt  with  injections  is  stopped 
exce])t  in  the  cases  ha\"ing  contimious  discliarge  i)roceeding  from  the 
anterior  urethra,  as  demonstrated  by  the  author's  seven-glass  test. 
Astringents  are  preferred  unless  infection  is  present,  when  antiseptics 
are  required.     Both  are  used  weak  and  not  oftener  than  twice  a  day. 

Irrigations  with  the  catheter  and  syringe  are  more  valuable  than 
hand  injections  and  should  be  carried  out  as  detailed  in  anterior  acute 
lu'cthritis,  with  a  frequency  of  once  or  even  twice  a  day  of  astringent 
and  antiseptics  alternating,  or  of  both  combined,  in  very  weak  and 
ascending  strengths  of  nitrate  of  silver.  After  urination  by  the 
patient  a  reflux  catheter  is  passed  to  the  bulb  or  to  the  locality  of 
subjective  and  objective  sensitiveness  to  iu*ine  and  palpation  and  then 
the  washing  is  performed.  The  solutions  must  be  hot  to  tolerance, 
the  pressure  gentle,  and  there  must  be  no  unfa\'orable  reaction  in 
pain,  spasm  or  tenesmus. 

lietrojections  are  more  serviceable  in  posterior  urethritis,  but  may 
be  employed  in  anterior  disease  also.  The  bladder  is  filled  wuth  a 
mild  hot  antiseptic  through  a  soft-rubber  catheter  in  the  earlier  period 
of  the  treatment,  but  later  when  sounds  are  in  use  through  the  author's 
irrigating  sound,  which  combines  dilatation  with  retrojection  at  a 
single  passing  of  one  instrument.  When  the  bladder  is  copiously  filled 
but  not  painfully  distended  the  instrument  is  withdrawn  and  the 
viscus  evacuated  under  Nature's  own  pressure  and  fimction,  thus 
washing  the  urethra  from  end  to  end,  cleansing,  sterilizing,  stimulating 
and  healing  it.  The  treatment  is  repeated  once  in  three  days.  There 
should  be  no  vesical  disturbance  or  other  disquieting  reaction.  For 
sterilizing  the  bladder  itself  the  fluid  should  be  retained  by  the  patient 
for  a  short  time  before  passing  it. 

The  instillations  are  best  of  all,  especially  when  used  alternately 
with  the  irrigations.  The  methods  are  three:  (1)  Soft-catheter 
method,  (2)  Keyes-Ultzmann  method,  and  (3)  Bangs's  method. 
All  these  methods  agree  as  to  the  standard  solutions  of  astringents 
and  antiseptics,  as  already  noted,  localization  according  to  subjective 
and  objective  sjTnptoms,  repetition  every  one,  two  or  three  days  and 
quantities  varying  from  a  few  drops  to  1  or  2  drams. 

The  soft-catheter  method  consists  of  a  short,  velvet-eye,  soft-rubber 


GONOCOCCAL  CHRONIC  URETHRITIS  283 

catheter,  No.  10  or  12  French,  attached  to  the  author's  modifica- 
tion of  TTayden's  instillation  syringe,  fom])riscd  in  a  hub  flattened 
on  two  sides  to  prevent  rollin<^  and  a  larger  hole  to  accommodate 
thick  fluids.  The  fluid  is  drawn  up  into,  a  catheter  and  syringe 
assembled  and  then  instillated  into  the  urethra  by  passing  the  catheter 
to  the  bulb,  after  lubrication.  These  instillations  are  given,  as  a  rule, 
with  the  patient  standing  and  holding  a  basin  obliquely  beneath  his 
penis  in  order  to  catch  any  spurt  along  the  catheter.  It  is  not  neces- 
sary to  use  the  reclining  position,  which  is  reserved  for  patients  who 
faint,  with  the  Wolbarst  basin  between  the  thighs,  a  small  piece  of 
gauze  over  the  penis  to  receive  spatter,  another  under  it  to  protect  it 
from  the  basin  and  the  forceps  of  the  operator  holding  the  catheter 
from  slipping. 

The  sign  of  reaching  the  bulb  of  the  urethra  at  the  triangular  liga- 
ment is  important  and  should  be  learned  early  and  well.  The  catheter 
slips  easily  along  the  urethra  until  the  bulb  is  reached.  Occasionally 
the  bulbocavernosus  muscle  will  grasp  it,  giving  the  sense  of  gentle, 
consistent  resistance  without  jump  or  jerk.  If  this  muscular  action 
is  absent,  or  when  it  is  overcome,  the  catheter  encounters  a  jump  or 
jerk  which  marks  its  passage  out  of  the  bulb  into  the  membranous 
urethra.  It  should  then  be  withdrawn  about  a  half-inch,  which  restores 
its  tip  to  the  bulb  ready  for  the  medication. 

The  Keyes-Ultzmann  method  may  be  applied  to  the  anterior  urethra 
as  well  as  the  posterior  canal,  for  which  it  is  primarily  designed.  The 
Ultzmann  syringe  modified  by  Keyes  is  shown  in  Fig.  72,  and  with 
the  patient  in  the  reclining  position  is  passed  to  the  bulb  or  suspected 
site  of  lesion  and  then  the  syringe  is  slowdy  emptied  upon  the  mucosa 
as  the  instrmnent  is  withdrawn  while  the  patient  shuts  the  meatus  to 
retain  the  fluid  for  fifteen  to  thirty  seconds. 

The  Bangs  method  is  much  the  same  as  that  just  described,  with 
the  great  advantageous  difference  that  the  syringe  sounds  of  Bangs  are 
silver  Benique  instriunents,  with  a  very  small  tube  passing  through 
each,  and  made  in  sets,  of  which  even  sizes  are  usually  sufficient  from 
No.  14  to  32  French.  The  author  has  modified  the  instrument  by  putting 
finger  supports  on  the  sounds  at  their  hub,  which  prevent  them  from 
slipping  off  the  syringe.  Advance  in  the  size  of  sound  used  combines 
dilatation  with  the  instillation.  All  other  details  are  the  same  as 
the  Keyes-Ultzmann  method. 

Applications  rest  on  diagnosis  with  the  bougie-a-boule  of  definite 
foci  of  disease,  after  the  manner  detailed  under  examination  of  stricture 
on  pages  354  and  355.  By  choice  the  Bangs  sjTinge  sound  is  passed  to 
such  a  point,  carefully  measured  from  the  meatus,  if  instillations  are 
chosen. 

Surgical  measures  are  nonoperative  and  operative,  of  which  terms 
the  latter  is  employed  for  such  formal  procedures  as  urethroscopy  and 
cystoscopy,  which  may  combine  truly  surgical  details.  Nonoperative 
measures  comprise  dressings  which  are  rarely  needed  unless  the  dis- 
charge is  copious  and  soils  the  underwear  of  the  patient.    The  chief 


284  CHROXIC  URETIIRITTS 

are  dilatation  ■without  or  Avitli  irrigation,  massag'c,  irrigations,  retro- 
jections  and  ointment  applications.  Dilatation  overcomes  soft  or 
dense  infiltration  and  avoids  organic  strictm-e.  A  straight  m'ethral 
sound  may  be  passed  in  order  to  gain  the  patient's  confidence.  At 
first  one  number  smaller  than  the  bougie-a-boule  is  used  to  locate 
the  lesions  and  then  ascending  one  number  at  a  time  until  the  desired 
diameter  is  secured.  There  should  never  be  any  blood  and  never 
marked  secondary  irritation.  Bangs's  syringe  sounds  may  be  passed 
in  ascending  mnnbers  in  the  same  way  through  the  infiltration  until 
it  is  enlargeil  to  the  ])ro])er  size.  The  nonirrigating  straight  Kollmaim 
dilator,  protected  with  a  rubber  cover  against  pinching  the  mucosa  in 
the  joints  of  its  blades,  may  also  be  inserted  if  the  lesion  accepts  No.  24 
French  at  first  and  then  dilatation  not  to  exceed  one  mmiber  or  even  a 
fraction  of  one  number  at  a  time  is  performed.  By  the  same  steps 
the  irrigating  instrument  may  be  used,  and  under  slight  pressure  mild 
astringent  and  antiseptic  solutions,  as  already  enumerated,  may  be 
employed.  ^Massage  may  be  applied  to  the  mucosa  upon  any  of  the 
solid  instruments  or  the  dilators  before  their  expansion.  Massage 
is  fully  discussed  under  its  own  head.  It  is  secured  by  the  act  of 
dilating  itself  and  by  digital  methods  along  the  urethra  held  on  the 
stretch  upon  a  straight  or.  other  sound  passed  to  the  bulb  of  the  urethra 
and  finally  by  the  reasonably  rapid  but  always  gentle  passing  of  a 
fiexible  bougie-a-boule  from  meatus  to  bulb.  Decongestion  follows  the 
cold  or  the  heat  of  steel  instruments  as  well  as  the  massage,  and  benefit 
is  seen  in  soft  infiltrations,  folliculitis  and  general  catarrhal  indolence. 
There  should  be  no  reaction  in  pain,  increased  discharge  or  blood. 

Traumatism,  physical,  thermal  or  chemical,  will  convert  a  soft  infil- 
tration into  a  hard  node  or  stricture,  so  that  gentleness,  moderate  heat, 
weak  solutions  and  weekly  treatments  by  these  methods  alone  are 
indicated,  beginning  about  one  month  after  the  discharge  and  active 
treatment  have  ceased,  as  premature  treatment  is  as  irritating  as  over- 
energetic  measures. 

The  irrigating  sounds  are  a  means  of  retro jection,  dilatation  and 
massage  by  the  one  passage  of  a  single  instrument.  The  author's 
models  are  preferred.  These  are  described  in  Chapter  VII  on  the 
Treatment  of  Stricture  on  page  308.  They  are  passed  cold,  massage  is 
performed  upon  their  shafts  if  desired  and  then  the  retrojection  is  done 
by  gently  filling  the  bladder  with  a  mild  warm  antiseptic  to  painless 
distention  and  then  permitting  the  patient  to  evacuate  it.  The  weak 
solutions  of  nitrate  of  silver  are  the  best,  alternating  with  argyrol  2 
to  5  per  cent.,  protargol  0.5  to  1  per  cent,  and  ])otassium  permanganate 
1  in  10,000  to  1  in  2000  by  gradual  increase. 

The  ointment  sounds  are  not  very  reliable  or  valuable  because  the 
mucosa  of  the  urethra  does  not  absorb  the  salves  readily  and  because 
its  musculature  has  a  definite  tendency  to  eject  the  salve  as  a  foreign 
body.  The  author's  model  has  advantages  as  follows:  (1)  The 
standard  curve  of  the  urethral  sound  with  its  tip  shortened;  (2)  a  blunt 
rounded  tip  which  does  not  traumatize;  (3)  an  inner  tube  to  carry  the 


GONOCOCCAL  CHRONIC  URETHRITIS  285 

ointment  to  the  base  of  the  curve,  which  permits  easy  chuiif^c  of  the 
ointment  and  sterilization  of  the  sound  itscilf;  (4)  a  lar^c  rcservcjir  of 
hard  rubber  for  the  oiiitnieiit,  of  whicJi  th(;r(!  sliould  he  several  for 
changing  the  treatment.  Th(!  ointment  sound  is  passed  exactly  like 
the  standard  instrument,  and  when  its  beak  reaches  the  point  to  be 
treated  a  small  quantity  of  the  salve  is  squeezed  out  by  screwing  the 
handle  of  the  reservoir  down. 

The  cupped  sound  is  like  the  standard  sound,  with  numerous  depres- 
sions cut  into  all  faces  of  the  shaft  for  a  short  distance  proximal  to  the 
curve.  They  are  likewise  not  reliable  because  the  salve  is  apt  to  be 
wiped  out  of  the  cups  during  introduction.  The  ointment  should  be 
of  weak  chemical  strength  and  may  duplicate  the  preparations  used  in 
the  irrigation  and  instillations,  such  as  alum  and  zinc  sulphate  grains 
0.5  to  1  to  the  ounce  (1  in  1000  to  1  in  500)  as  astringents,  argyrol  2 
to  10  per  cent,  as  an  antiseptic  and  ichthyol  0.5  to  5  per  cent,  as  a 
stimulant. 

The  operative  measures  are  included  under  anterior  urethroscopy, 
which  from  meatus  to  bulb  will  detect  the  individual  lesions  and  verify 
the  diagnoses  of  other  measures.  All  details  of  equipment  and  technic 
are  fully  discussed  in  the  Chapter  on  Urethroscopy,  page  616.  For 
our  purposes  here  the  following  details  suffice: 

The  urethroscope,  either  of  the  open-end  Chetwood  type  or  of  the 
side  fenestrum  Buerger  or  McCarthy  type,  is  the  best  instrument 
for  verifying  the  data  found  with  the  bougie-a-boule  and  then  of 
treating  the  lesions  surgically  by  gentle  curetting  and  incising  dis- 
eased spots  or  chemically  with  graded  caustics  or  thermally  with  the 
actual  cautery  or  electrically  with  the  galvanocautery,  the  high-fre- 
quency current  of  Oudin,  the  relaxing  current  of  d'Arsonval  or  galvani- 
zation or  faradization.  In  the  last  two  the  negative  pole  must  always 
be  within  the  urethra  and  a  large  positive  pole  carefully  applied  to 
the  abdomen  or  back.  In  general  the  mild  means  which  do  not 
destroy  the  mucosa  should  always  be  preferred,  because  such  destruc- 
tion of  the  lining  may  be  more  extensive  than  apparent  at  the  moment 
of  treatment  and  prove  to  be  the  first  step  in  traimiati:  stricture. 
Small  syringes  with  very  long  silver  tips  have  been  devised  for  applying 
antiseptic  and  astringent  medicines  directly  into  diseased  crypts  and 
follicles  and  are  of  value  if  carefully  used. 

The  urethroscope,  when  skilfully  employed,  will  locate  any  lesion 
and  submit  it  to  treatment.  As  pointed  out  in  the  Chapter  on  Diag- 
nosis it  is  necessary  to  be  perfectly  familiar  with  the  healthy  mucosa 
in  its  normal  gloss  and  color,  vascularity,  edema,  elasticity  and  crj^ts. 
These  must  be  distinguished  from  the  lesions  found,  such  as  excoria- 
tions, exfoliations,  ulcers  and  infiltrations  and  diseased  follicles  and 
glands.  Local  applications  of  styptics,  astringents,  antiseptics  and 
stimulants,  of  the  high-frequency  cm'rent  of  Oudin,  of  curettement 
and  incision  may  readily  be  made  through  the  m-ethi'oscope.  These 
methods  of  treatment  are  more  valuable  in  the  complications  than  the 
simple  chi'onic  lesions. 


286  CHROXIC  URETHRITIS 

General  frequency  of  treatment,  with  all  the  foregoing  localized 
methods,  should  be  without  any  irritation  whatever  and,  as  a  rule, 
the  number  of  a})plications  begins  with  once  a  <lay  for  the  mild  irriga- 
tions, with  three  times  a  week  for  the  instillations,  and  with  once  in 
five  to  ten  days  for  the  instrimientation,  massage  and  electrotherapy. 
The  kinds  of  treatment  alternate  so  that  the  same  detail  does  not  recur 
for  longer  periods,  although  the  same  type  can  do  so  within  the  i)re- 
scribed  limits.  Distinctly  stinuilating  ai)])lications  are  tempered 
finally  to  mikl  astringency  and  then  cease  to  be  followed  by  the  gentle 
instrumentatioif  after  a  period  of  rest  and  at  the  longer  intervals. 

Aff'Tfrcdtmcnt, — After  the  lesions  are  removed  and  when  there 
remain  only  a  few  small  light  catarrhal  shreds  or  a  mucous  discharge 
or  a  watery  moisture,  of  which  none  attracts  the  patient's  attention, 
it  is  best  to  leave  him  alone  for  from  two  to  foiu-  weeks  with  only  the 
persistence  of  good  management  and  hygienic  regulations.  These 
should  be  ])rocured  by  observing  the  patient  each  week  and  examining 
his  urine  and  organs  at  each  such  visit.  It  is  well  to  permit  in  this  way 
Nature  to  exercise  her  full  powders  of  resolution  imdisturbed  before 
resuming  active  measures  again.  Of  course,  it  is  noted  that  no  gono- 
cocci  exist  in  any  exudate  before  this  rest  from  treatment  is  begun, 
and  the  patient  must  be  carefully  instructed  to  return  at  once  should 
any  difference  in  his  condition  appear. 

Cure. — Cure  rests  on  the  same  principles  laid  dowm  imder  this  head- 
ing for  acute  anterior  disease  on  page  73.  The  urine  must  be  free  of 
mucus,  pus  or  shreds  and  remain  so,  without  relapse,  under  irritation 
by  instillations,  diet  and  the  beer  test.  A  few^  mucous  shreds,  with 
little  or  no  pus  and  absolutely  without  the  gonococcus  on  smear  and 
culture  during  a  month  or  more  of  repeated  examination,  may  be 
allowed.  Examination  of  the  semen  in  a  condom  worn  at  night  to 
secure  an  emission  is  the  last  test  and  repeats  the  condition  mider 
which  discharge  during  intercourse  brings  out  hidden  gonococci. 

Irrigation  Method. —  Cautions  and  preliminaries  all  duplicate  in 
every  way  those  of  this  method  in  acute  urethritis,  as  do  likewise 
associated  methods  of  cure.  In  the  same  category  are  the  internal 
measures  graduated  according  to  reaction  and  results. 

Local  measures  comprise  the  same  three  methods  of  irrigation  as 
the  acute  urethritis:  Syringe-and-catheter  technic,  ^^alentine-Janet 
method  and  Chetwood  double-current  irrigation  (A'hich  might  be 
called  irrigations  without  dilatation),  and  irrigation  with  dilatation. 
In  all  these  steps  without  exception  the  patient  always  first  urinates 
in  the  presence  of  the  urologist  and  if  insufficient  urine  is  passed  the 
anterior  urethra  should  be  flushed  as  a  preliminary  before  passing 
the  deep  urethra  into  the  bUulder.  This  viscus  is  filled  with  any  of 
the  standard  antiseptic  and  astringent  solutions,  given  on  page  73, 
and  next  the  deep  urethra  and  anterior  urethra  are  irrigated  as  the 
instrument  is  withdrawn.  Then  evacuation  of  the  bladder  contents 
cleanses  the  canal  as  a  retrojection. 

In  irrigation  with  dilatation,  massage  of  the  mucosa  by  the  stretch- 


GONOCOCCAL  CHRONIC  URETHRITIS  287 

ing  is  good  additional  treatment,  secured  by  the  KolLmann  irrigating 
and  nonirrigating  dilators,  by  standard  flexible  or  steel  sounds  with 
irrigation  following,  or  by  the  author's  irrigating  sounds. 

The  soft,  flexible  instruments  should  precede  any  form  of  rigid  instru- 
ment until  the  response  to  dilatation  is  known  and  all  dilatation  should 
be  begun  very  late  in  the  treatment,  so  as  not  to  convert  resorbing  and 
soft  infiltrations  into  dense  and  persistent  lesions.  If  insufficient  urine 
is  passed  the  anterior  urethra  should  be  flushed  with  the  syringe-and- 
catheter  method  as  a  preliminary.  In  all  methods  the  duration  of 
dilatation  is  five  to  ten  minutes,  its  repetition  every  three,  five  or 
seven  days,  with  preference  for  the  long  intervals,  and  no  pain,  blood 
or  tramnatism  should  accompany  its  increase  of  one  number  of  the 
French  scale  and  no  more  at  each  treatment.  All  mechanically 
expanding  instruments  are  advanced  a  fraction  of  a  number  at  a 
time  if  the  slightest  traumatism  occurs.  There  should  be  no  reaction 
to  these  dilatations. 

The  Kollmann  irrigating  dilators  are  passed  exactly  like  a  sound, 
with  the  blades  closed  and  after  thorough  lubrication  with  boro- 
glyceride  or  other  soluble  preparation.  When  in  place  in  the  midline 
of  the  body  with  the  penis  held  stretched  upon  it  the  blades  are  slightly 
opened  and  the  irrigating  fluid,  under  gentle  head,  and  mild  concentra- 
tion and  easily  tolerated  heat  are  turned  on.  After  about  1  or  2  quarts 
have  flowed  through  the  canal  the  reservoir  is  disconnected  and  the 
dilatation  continued  for  the  rest  of  the  prescribed  period.  The  blades 
are  then  nearly  closed  in  order  to  avoid  pinching  the  mucosa.  Should 
this  occiu"  the  blades  are  opened,  the  irrigation  resumed  and  continued 
while  they  are  again  closed  partly  and  the  instrument  is  removed  while 
the  fluid  keeps  the  mucosa  back. 

The  KolLmann  nonirritating  dilators  are  protected  with  a  rubber 
cover  suggested  by  Valentine,^  well  smeared  with  a  soluble  lubricant, 
passed  into  the  m-ethra  like  a  sound  and  then  expanded  a  part  or  whole 
number.  It  is  closed  fully  on  withdrawal  because  the  rubber  cover 
shields  the  mucosa.  Irrigation  is  then  performed  by  any  method 
selected,  preferably  with  the  syringe-and-catheter  technic  in  the 
author's  opinion. 

The  standard  flexible  or  steel  sounds  are  gently  passed  into  the 
bladder  and  when  removed  are  followed  by  irrigation,  as  just  stated. 
This  technic  is  excellent,  but  has  the  disadvantage  of  two  inciu-sions 
either  by  the  sound  and  catheter  or  the  sound  and  a  stream  of  fluid  for 
the  irrigation. 

The  author's  irrigating  sounds  in  slowly  ascendmg  sizes  are  far  pref- 
erable to  any  of  these  other  methods.  All  their  details  are  described 
under  treatment  of  Stricture  on  page  358.  After  passing  one  into  the 
bladder  the  obturator  is  withdrawn,  the  viscus  washed  clean  and  then 
filled  with  any  of  the  standard  antiseptic  and  astrmgent  solutions, 
which  may  also  be  instillated  into  the  urethra  as  the  sound  is  with- 

*  Loc.  cit. 


288  CHRONIC  URETHRITIS 

drawn.  Then  evacuation  of  tlic  bladder  flushes  the  uretlira  from 
behind  forward.  Tliis  sound  requires  one  incursion  for  all  four  pur- 
poses— ililatation,  washinfj  of  the  blailder,  instillation  of  the  urethra 
and  irrigation — or  for  any  two  or  tlu'ce  of  these  anns. 

Ajtertreaimcut. — AVhen  the  case  seems  to  be  at  an  end  the  after- 
treatment  and  ohser\ation  are  the  same  as  those  discussed  under  the 
conservative  method  on  ])age  2S(). 

Cure. — Cure  in  all  its  standards  is  the  same  as  that  outlined  for  the 
expectant  treatment  on  i^atje  2S(k 

Posterior  Gonococcal  Chronic  Urethritis. — The  symptoms  are  sub- 
jective and  objective  with  the  general  features  noted  in  the  opening 
paragraphs  on  symptoms  in  that  the  objecti\c  usually  predominate 
over  the  subjective,  which  are  divisible  into  three  general  classes — 
urinary,  sexual  and  general.  The  subjective  urinary  symptoms  are 
frequency,  tenesmus  and  pain,  Avhich  are  usually  more  marked  the 
nearer  the  lesions  are  to  the  sphincter  of  the  bladder.  The  frequency 
may  be  very  little  or  marked  and  rather  urgency  than  true  frequency. 
It  is  increased  by  congestion  from  intercourse,  diet  or  drinking,  which 
concentrates  the  urine,  and  decreased  by  diluents  which  render  it  bland. 
Tenesmus  rests  on  the  same  factors  and  may  be  slight  or  severe.  It 
rarely  has  the  intensity'  of  acute  involvement  but  usually  is  a  sense 
of  uneasiness  directly  after  urination.  Pain  may  be  due  to  acidity  of 
the  urine,  ulcerations,  or  the  obstruction  of  infiltrations  and  polypi. 
It  is  usually  not  important  except  in  oversensitiA'c  individuals. 

The  subjective  sexual  symptoms  are  in  great  A'ariety  and  among  the 
most  troublesome  on  account  of  nervous  and  psychic  effects.  They 
also  vary  with  intensity  and  frequency  and  usually  comprise  deep- 
seated  perineal  pain  on  erection  and  ejaculation,  loss  of  normal  sexual 
enjoyment,  premature  ejaculation,  nocturnal  emissions,  which  may 
be  normal,  i)urulent  or  bloody,  decreased  desire  and  finally  prostatitis, 
seminal  vesiculitis  and  frequent  attacks  of  epididymitis.  The  pros- 
tatitis shown  under  pathology  may  be  of  the  exfoliating  epithelial 
t\-pe  or  of  the  purulent  type,  both  of  which  exudates  may  appear 
only  during  defecation  to  the  alarm  and  discomfort  of  the  patient.  The 
epididymitis  probably  depends  on  prostatitis  and  seminal  vesiculitis 
and  appears  usually  without  known  exciting  cause.  Seminal  vesicu- 
litis is  usually  of  the  relapsing  tA-pe  with  hardly  any  exudate  for  a 
short  time  and  then  copious  amoimts  for  a  longer  period.  In  the 
strict  sense  the  SATiiptoms  due  to  prostatitis,  seminal  \'esiculitis  and 
epididj-mitis  are  the  chronic  complications  of  posterior  chronic  ure- 
thritis, and  are  fully  discussed  under  this  heading  on  page  313.  The 
discharge  may  be  free  but  scanty  or  only  shreddy.  Thus  arise  the 
frequent  drops  appearing  during  the  day  and  relapsing  from  time  to 
time  or  the  drop  shown  only  in  the  morning.  In  some  cases  there  is 
no  discharge  which  the  patient  sees  except  in  the  urine,  as  shreds 
otherwise  complications  in  the  prostate  and  vesicle  are  to  be  looked 
for. 

The  general  or  systemic  subjective  symptoms  are  absorptive,  nervous 


GONOCOCCAL  CHRONIC  URETHRITIS  289 

and  digestive.  Many  patients  show  certain  absorption  phenomena, 
especially  in  complicated  cases  leading  to  anemia,  depreciation  of  gen- 
eral health,  and  the  like,  and  arthritis,  which  have  already  been  dis- 
cussed under  complications.  The  nervous  symptoms  are  highly  various 
and  constitute  usually  worry,  irritability  and  a  great  list  of  neuralgic 
pains  and  queer  sensations,  referable  to  various  portions  of  the  sexual 
organs,  more  commonly  the  glans  penis,  perineum,  groins,  testicles, 
thighs  and  loins.  These  may  be  constant  but  much  more  commonly 
come  and  go  largely  according  to  the  patient's  physical  weariness  and 
are,  therefore,  most  numerous  toward  the  end  of  the  day.  The  diges- 
tive elements  depend  largely  on  the  mental  worry  and  are  loss  of  appe- 
tite and  constipation.  These  general  symptoms  sometimes  continue 
when  there  is  no  longer  an  objective  basis  and  are,  therefore,  difficult 
of  explanation.  It  is  at  least  thinkable  that  those  conditions  in  the 
blood  which  lead  to  the  complement  fixation  observations  may  finally 
work  out  as  the  objective  causes. 

Objective  symptoms  are  also  urinary,  sexual  and  general,  but 
depend  as  to  character  on  whether  the  case  is  one  of  the  slow  progres- 
sive type  of  gonococcal  chronic  urethritis  or  one  of  the  quiescent 
recurrent  type  with  acute  and  subacute  exacerbations. 
^  The  urinary  signs  are  that  in  the  ordinary  two-glass  test  both  glasses 
show  discharge,  either  in  free  pus  or  shreds,  in  accordance  with  the 
nature  and  activities  of  the  process.  The  reason  for  tjbis  fact  is  that 
the  first  glass  of  urine  does  not  wash  away  all  the  pus  and  clinging 
shreds  from  the  posterior  urethra  although  it  does  show  the  larger 
quantity.  True  prostatic  elements  and  seminal  vesicular  contents 
may  be  in  the  second  glass,  either  because  these  organs  are  compli- 
cated with  the  disease  or  because  incidentally  in  the  process  of  urina- 
tion they  have  partially  been  evacuated.  Careful  microscopy  alone 
proves  the  nature,  state,  source  and  infectiousness  of  such  pus  or 
shreds  and  the  presence  or  absence  of  spermatozoa.  The  seven- 
glass  test  of  the  author  shows  pus  in  the  Anterior  Irrigation  Glass 
gravitated  into  the  anterior  urethra  from  the  posterior  urethra,  nothuig 
in  the  Anterior  Control  Glass,  abundance  of  detritus  in  the  Posterior 
Urethral  Glass  which  like  Glass  I  will  show  various  posterior  urethral 
elements  whose  nature  depends  on  the  microscope.  The  Bladder  Glass 
is  negative,  the  Prostatic  Glass  by  massage  may  be  negative  or  show 
complicating  lesions,  while  the  same  deductions  are  made  from  the 
findings  in  the  Right  and  Left  Seminal  Vesicular  Glasses.  In  other 
words,  if  only  the  posterior  urethra  is  involved,  and  its  annexa  normal, 
the  last  three  glasses  will  be  practically  or  actually  negative.  The 
laboratory  qualifies  the  source  of  the  pus  and  desquamated  detritus 
and  the  organisms  as  gonococci,  and  the  complement  fixation  test  as 
positive  in  cases  of  long  standing  or  with  complications. 

The  objective  sexual  symptoms  are  referred  to  the  prostate,  seminal 
vesicles  and  testes. 

Treatment. — Description  of  management  is  completed  in  Chapter  IX 
on  General  Principles  of  Treatment. 
19 


290  CHROXIC  URErilRITIS 

Of  physical  ineasnros  in  the  dcchniiii:;  stage  the  stiiniilation  of  general 
massage  is  good  locally  ami  used  systeniically  is  equivalent  to  exercise 
in  its  hjTDcreraic  effects.  Hydrotherapy  in  the  acute  and  chronic 
periods  will  decongest  and  stinuilate.  Heat  is  better  than  cold  because 
the  latter  so  often  induces  catarrh.  Klectrotlu'rai)y  must  be  used 
only  in  the  declining  period.  Galvanism  for  cataphoresis  is  indicated 
locally  in  the  anterior  urethra.  In  the  posterior  urethra  the  direct 
d'Arsonval  current  may  be  used  with  the  insulated  metal  electrode, 
measuring  100  to  400  milliamperes  intensity  of  current,  for  twenty 
mimites  in  duration  and  one  to  three  tunes  in  frecpiency  per  week. 
The  high-potential  ]xirtially  insulated  Aacuum  electrode  attached  to 
the  negatiA'e  pole  of  the  standard  multiple-plate  high-speed  static 
machine  with  the  positive  pole  grounded  may  be  used.  A  spark  gap 
of  a  I  inch  sets  the  intensity,  ten  minutes  the  duration  and  twice  a 
week  the  frequency.  Xo  rectal  treatment  is  necessary.  The  respec- 
tive action  of  these  cm-rents  is  diathermic  for  the  d'Arsonval  and 
actinic  and  germicidal  for  the  static  machine.  The  results  of  each 
modality  are,  therefore,  destruction  of  the  infecting  organisms  by 
the  local  temperature  produced  in  the  diathermic  current  and  by  the 
actinic  effect  of  the  high-potential  static  cm-rent. 

The  d'Arsonval  high-frequency  current  in  the  autocondensation 
method  stimulates  elimination  and  acts  as  a  restorative.  The  static 
wave  current  with  a  long  electrode  placed  ovev  the  spine  attached 
to  the  positive  pole  of  a  high-speed  static  machine  has  also  a  very 
beneficent  restorative  effect. 

The  medicinal  measures  follow  these  leads  by  supporting  the  system, 
regulating  the  intestinal  absorption,  preventing  toxemia  and  alleviat- 
ing catarrhal  tendencies  through  stimulating  the  mucosa  to  better 
action — all  by  systemic  administration  of  tonics  for  the  blood,  ner- 
vous and  digestive  systems  and  mucous  membranes.  By  local  use 
in  the  declining  stage  mucous  discharge  is  allayed  by  very  mild  hand 
injections,  irrigations  and  the  physical  measures  already  given.  Later 
in  the  disease  instillation  and  cautious  instrumentation  are  begun. 
Details  are  described  under  anterior  gonococcal  acute  and  chronic 
disease.  Applications  through  the  urethroscope  are  rarely  necessary. 
The  prostate  may  be  soft  from  sympathetic  congestion  or  from  early 
involvement  or  late  lesions  of  follicular  or  parenchymatous  prostatitis 
which  makes  the  case  pass  over  into  one  of  chronic  complications  and 
is  discussed  in  Chapter  V.  The  seminal  vesicles  on  one  or  both 
sides  are,  like  the  prostate,  negative  in  the  typical  uncomplicated  case 
and  show  even  on  a  full  bladder  nothing  or  at  most  sympathetic  con- 
gestion. In  the  complicated  cases,  however,  they  may  show  any 
degree  of  inflammation,  infiltration  and  chronic  abscess  formation. 
The  testes  and  vasa  deferentia  follow  the  rule  of  both  the  preceding 
organs,  being  negative  in  cases  of  true  posterior  disease  but  showing 
almost  any  stage  of  involvement  of  the  ei)ididymis  and  other  portions 
of  the  vas  in  chronic  persistent  or  chronic  relapsing  inflanunation. 
The  interval  between  the  testis  and  its  epididymis  of  the  normal 


GONOCOCCAL  CHRONIC  URETHRITIS  291 

organs  should  always  be  felt  and  when  it  is  absent  further  investiga- 
tion should  be  stimulated  in  the  epididymis  and  along  the  vas  up  to 
the  inguinal  canal  and  through  the  rectum  along  the  ampulla  close 
to  the  seminal  vesicle.  There  is  frequently  no  ol)j(!ctive  basis  for  the 
uncertain  and  irregular  neuralgic  pains  complained  of  by  many 
patients,  but,  on  the  other  hand,  careful  exploration  often  reveals  an 
unsuspected  focus. 

Urethroscopy  belongs  distinctly  to  the  objective  analysis  of  gono- 
coccal chronic  urethritis  but  is  deferred  to  Chapter  XII  of  this  work 
because  it  is  so  much  a  science  itself.  The  objective  general  symptoms 
are  usually  absorptive,  nervous  and  digestive  and  the  more  pro- 
found manifestations  depend  entirely  on  the  severe  examples  of  the 
disease,  especially  with  complications,  as  stated  in  Chapter  V  on 
page  332.  The  absorptive  signs  are  summed  up  in  the  general  term 
toxemia  and  are  manifested  during  the  earlier  and  severe  periods  by 
fever,  which  disappears  as  the  case  settles  into  fixed  chronicity;  by 
anemia  in  the  blood  and  sometimes  by  loss  of  weight.  In  this  class 
would  belong  the  positive  complement  fixation  test.  The  nervous 
symptoms  are  general  unrest,  neurasthenia  and  excited  reflexes  really 
dependent  on  absorption  and  worry.  Neuritis  and  neuralgia  may  be 
present  and  give  their  characteristic  findings,  the  former  tenderness 
over  the  nerve  and  irregular  changes  in  its  function  and  the  latter 
often  without  objective  data.  The  digestive  elements  are  the  coated 
tongue  and  the  appearance  of  being  out  of  health  and  constipated, 
which  may  proceed  from  either  the  absorption  or  the  medication. 

Diagnosis. — This  depends  on  its  usual  four  factors  which  should  be 
carefully  studied  in  Chapter  VIII  on  General  Principles  of  Diagnosis. 
The  history  of  the  acute  attack  shows  obstinate  and  severe  sjTnptoms, 
sometimes  improper  and  overactive  management,  followed  by  persistence 
of  symptoms  in  a  low  and  stationary  degree  or  a  slowly  progressing  and 
relapsing  degree.  The  sjTiiptoms  vary  in  their  activity  and  as  stated  are 
urinary,  sexual  and  systemic.  The  frequency,  urgency  and  tenesmus 
of  urination  are  the  most  important,  associated  with  the  chronic  dis- 
charge or  drop.  The  physical  examination  of  the  urine  in  test-glasses, 
especially  by  the  seven-glass  test  of  the  author,  shows  characteristic 
and  abundant  exudate  in  the  posterior  urethral  glass.  The  anterior 
urethral  and  control  glasses  may  be  negative  and  such  elements  as 
they  contain  will  be  from  the  posterior  urethra.  Urethroscopy  is 
important  and  applied  in  the  methods  set  down  in  Chapter  XII  on  that 
subject.  Cystoscopy  should  always  be  performed  when  the  tenesmus 
is  great  in  order  to  be  sure  that  the  bladder  has  not  been  mvaded.  The 
laboratory  reveals  the  presence  of  the  gonococcus  and  the  complement 
fixation  test  is  advisable  in  the  more  marked  cases.  The  treatment 
step  by  step  serves  to  corroborate  all  the  other  findings. 

Treatment. — Posterior  gonococcal  chronic  urethritis  must  be  treated 
by  all  the  methods  usually  employed  for  combating  this  disease,  remem- 
bering that  the  annexa  of  this  portion  of  the  canal  are  very  important 
structures. 


292  CHRONIC  URETIIRiriS 

Preventixe  atid  abortive  treatments  are  literally  nil,  altliou2;li  SooH 
juduniient  in  the  diaj^niosis,  due  attention  to  the  patholoiiieal  lesions, 
full  respect  for  the  sNinj^tonis  and  precise  selection  of  gentle  means  of 
treatment  will  do  much  to  ]H-event  posterior  acute  lesions  from  becom- 
ing chronic  and  especially  from  becoming  comjilicated.  It  is,  of  course, 
not  possible  to  abort  the  transition  from  acute  to  chronic  lesions. 

Ixeference  to  Chajiter  IX  on  General  Principles  of  Treatment  will 
supply  all  facts  on  management. 

Curative  Treatment. — Its  procedures  are  two:  the  expectant  method 
and  the  irrigation  method,  each  having  the  same  general  essentials  as 
have  been  noted  under  Antc-rior  Gonococcal  Chronic  Urethritis  on 
page  53. 

The  same  accepted  and  established  general  ])rin(iples  of  gentleness 
in  dealing  with  the  mucosa  ai)])ly  in  this  region  as  in  the  anterior 
urethra  and  of  local  and  systemic  stimulating,  sui)i)orting  and  restoring 
measures. 

Subjecti^■e  local  symptoms  have  been  gwen  as  lU'inary  in  frequency, 
tenesmus,  pain  and  discharge,  as  sexual  in  deep  perineal  (hordee, 
disturbed  ejaculation  and  coitus,  nocturnal  emissions  and  congested 
prostate,  seminal  vesicles  and  testicles  without  true  com])lications. 
The  systemic  subjective  signs  are  those  of  absorption  and  disordered 
digestion  and  nervous  system.  Corroboration  of  all  these  symptoms 
rests  with  objective  examination  and  in  particular  with  the  author's 
se\Tn-glass  test  and  urethroscopy.  Often  the  objective  signs  are  the 
only  definite  symptoms. 

Physical  measures  compromise  the  standard  three — massage,  hydro- 
therapy and  electrotherapy,  each  requiring  brief  notice  as  extended 
discussion  is  elsewhere.  Massage  is  efficient  in  controlling  relaxed 
conditions  by  indirectly  stimulating  the  mucosa  and  aiuiexa  of  the  deep 
urethra  especiall}^  when  the  passive  congestion  extends  to  the  prostate 
and  seminal  vesicles  without  true  inflammation.  Massage  of  the  deep 
urethra  may  be  done  while  an  instrument  is  in  situ  exactly  as  in  the 
anterior  urethra  with  the  ever-present  caution  against  vigor  sufficient 
to  bruise  the  prostate.  For  this  reason  it  should  always  be  begun  with 
soft,  flexible  instrimients  until  tolerance  is  known.  If  well  borne,  metal 
instriunents  may  later  be  used  but  in  the  average  case  had  best  be 
omitted  altogether.  Hydrotherapy  is  local,  applied  to  the  urethra  or 
the  rectimi  or  general  to  the  body  at  large.  Its  local  urethral  measures 
are  largely  covered  by  the  irrigation  treatment  in  any  of  the  three 
technics  discussed  on  page  71,  and  its  rectal  development  requires  hot, 
sometimes  cold,  normal  salt  solution  for  those  forms  of  passive  relaxa- 
tion also  benefited  by  massage  of  the  prostate,  seminal  vesicles  and 
urethra.  Its  details  are  reviewed  under  posterior  acute  urethritis  as 
irrigation  with  double-current  tubes  or  repeated  enemata  or  the  psy- 
chrophore  or  thermophore.  General  body  baths  are  not  of  much  value 
except  for  increasing  elimination  when  there  is  a  tendency  to  absorp- 
tion and  in  controlling  urethral  chill  and  other  occasional  ill  effects  of 
instrmuentation,  but  lic»t  sitting  baths  are  called  for  by  indolent  mucosa. 


GONOCOCCAL  CHRONIC  URETHRITIS  293 

Cold  may  be  applied  to  the  deep  urethra  with  sounds  of  medium  sizes, 
20-22-24  F.,  dipped  in  iced  water,  passed  every  three  or  four  days 
and  retained  for  ten  miiuites,  if  benefit  ensues.  Sharp  or  dull  neuralgic 
afterpains  indicate  cessation. 

The  electrotherapy  is  also  local  or  general  and  has  Ijeen  fully  dis- 
cussed under  Anterior  Chronic  Urethritis,  on  page  279,  as  to  equipment 
in  machines  and  electrodes  for  developing  and  applying  the  various 
modalities,  as  to  medicinal  supplies  and  as  to  sele(;tion  of  case  and 
duration  and  frequency  of  treatments.  The  electrodes  for  the  poste- 
rior urethra  must  have  the  form  of  sounds  for  suitable  i^enetration 
and  apposition.  Like  hydrotherapy,  electrotherapy  through  the 
rectum  is  of  benefit  and  requires  special  electrodes. 

Its  local  methods  are  either  posterior  urethral  or  rectal  or  both  in 
correlation  or  sequence.  In  the  posterior  urethra  if  the  purpose  is  to 
stimulate  relaxed  muscularis,  a  faradic  current  is  employed  through 
the  curved  electrodes  with  30  interruptions  to  the  second  corresponding 
with  the  normal  fibrillary  contractions  of  muscle  tissue  and  so  feeble 
in  intensity  as  not  to  be  measurable  but  so  strong  as  to  cause  painless 
physiological  thrill.  Either  pole  ma}^  be  put  into  the  urethra,  but  a 
large  indifferent  electrode  is  applied  to  the  abdomen.  Treatments 
persist  five  or  ten  minutes  unless  discomfort  or  pain  arises  and  visits 
like  those  for  instillations  are  every  other  day  dependent  on  results 
which  are  always  free  of  secondary  irritation.  There  is  no  after- 
treatment — the  less  meddling  the  better.  As  in  the  anterior  urethra 
the  glass  electrodes  may  be  employed  for  local  effect  in  two  w^ays. 
If  attached  to  the  negative  pole  of  the  high-speed  static  machine  the 
effect  is  sedative,  which  is  advisable  in  irritable  conditions;  but  if 
connected  with  the  positive  pole  of  the  machine  the  action  is  hyiDeremic, 
stimulating,  germicidal  and  actinic. 

In  rectal  application  a  static  machine  of  standard  type  is  used  with 
metal  electrodes  and  the  static  wave  current  for  relaxation  without 
infection.  The  connection  is  to  the  positive  pole  while  the  negative 
pole  is  gromided.  The  tension  of  current  is  that  of  a  spark  gap  of  |  to 
2",  according  to  effects,  with  a  frequency  of  interruption  of  150  to  200 
per  minute  and  a  duration  of  treatment  of  twenty  minutes  and  a  fre- 
quency of  visits  of  every  other  day  and  then  twice  a  week.  Intensity 
and  frequency  of  treatment  decrease  with  the  improvement  and  there 
is  no  aftertreatment.  The  results  are  a  painless,  profound,  alternating, 
physiological  tissue  contraction  and  relaxation — a  massage  more  local- 
ized and  energetic  but  less  traiunatic  than  digital  massage.  In  infil- 
tration with  infection  a  vacuiun  tube  in  the  rectmn  is  applied  over  the 
urethra  and  the  current  is  produced  by  a  static  machine  with  the  nega- 
tive pole  connected  to  the  electrode  and  the  positive  pole  grounded. 
Intensity  is  determined  by  a  spark  gap  of  |  to  1"  and  |  to  1  milliampere 
of  current  on  a  reliable  meter  in  series  with  the  negative  side  of  the 
machine.  The  duration  is  ten  minutes  and  the  frequency  of  visits  two 
to  three  times  per  week  with  longer  intervals  as  the  improvement  occurs, 
but  the  intensity  of  the  current  and  the  duration  of  treatments  are  not 


294  CIIROXIC  URETHRITIS 

changed.  The  results  are  (hie  to  aetinie  (hseharf^e  from  the  vaciiiun 
eleetrcxle  which  penetrates  tlie  tissue  from  two  to  six  JuiUimcters  and 
gross  tissue  contraction  proihiccd  hy  tlic  Iii,uii-])()tential  static  current. 
There  is  no  aftertreatment. 

Systemic  api)Hcation  is  discussed  un<lcr  this  toi)ic  in  Anterior  Chronic 
Urethritis  on  page  2S1;  but  it  nuist  he  rememhered  that  the  contin- 
uation of  the  symjjtoms  causing  worry  and  the  persistence  of  the 
lesioiis  inducing  absorption  are  in  posterior  chronic  urethritis  fertile 
causes  of  disturbances  in  digestion,  ehmination,  circuhition  and 
nervous  efficiency  requiring  restoration.  Electricity  is  of  value  in 
many  cases. 

^Medicinal  measiu'cs  are  systemic  and  local  and  serotherapeutic. 
The  systemic  medication  of  influence  on  the  urine  or  mucosa  comprise 
the  drinking  of  mineral  or  ])lain  water,  the  \'arious  urinary  diluents 
and  antisei)tics,  blennorrhagics,  and  sgxual  sedatives.  A  bland  urine 
prevents  irritation  and  aids  in  controlling  the  inflammation.  Anti- 
septics and  blennorrhagics  avoid  possible  transfer  of  infection  w'ith 
instrmnents  while  the  sexual  sedatives  allay  the  excitement  due  to 
irritating  lesions  or  the  passive  congestion  of  the  prostate  and  vesicles. 
Urethral  chill  after  instrumentation  is  corrected  in  sthenic  patients 
by  one  pill  containing: 

H — Morphin  sulphate       .      .      .     0.0078  to  0.0156  grammes  (grains  J  to  g) 
Tincture  of  aconite    .      .  0.0625  to  0.1875  grammes  (minims  1  to  3) 

Quinine  sulphate        .  .     0. 1875  to  0.3125  grammes  (grains  3  to  5) 

Asthenic  subjects  require  the  substitution  of   nitroglycerine,  grains  xio  to  5o  for 
the  aconite. 

In  sermntherapy,  as  outlined  in  Chapter  IX,  lies'a  measure  of  value 
in  building  uj)  bodily  resistance  against  infection  and  absorption. 
The  more  efficient  form  seems  to  be  acti^'e  unmunity  produced  by  the 
injection  of  gonococcal  or  mixed  bacterins;  but  passive  immunity  from 
injection  of  serums  may  also  be  tried.  Autogenous  bacterin  or  serum 
should  receive  first  attention  and  stock  products  second  choice  only 
after  unsatisfactory  results  with  the  former. 

The  local  medications  comprise  hand  injections,  instillations,  retro- 
jections,  dilatations  and  irrigations  and  the  methods  are  again  two, 
conservati^'e  and  irrigation.  Patients  cannot  safely  use  hand  injections 
in  the  deep  urethra  which  are  therefore  abandoned  in  favor  of  retro- 
jections  performed  with  the  soft  catheter  or  the  reflux  catheter  or  as 
detailed  under  sounds  and  dilators  in  later  paragraphs  with  the  author's 
irrigating  sounds  or  the  Kollmann  irrigating  dilator.  A  soft,  velvet-eye, 
rubber  catheter  No.  16,  18  or  20  Fr.  is  slowly  passed  into  the  bladder, 
which  after  evacuation  is  filled  with  one  of  the  standard  astringents  or 
antiseptics,  listed  on  page  73,  several  times  until  clean  and  then  left 
full  while  the  catheter  is  withdrawn  and  the  same  or  slightly  stronger 
solution  is  instillated  in  very  small  quantity  and  with  greatest  gentleness 
along  the  posterior  urethra.  The  patient  then  voids  his  medicated 
bladder-contents,  completing  the  treatment,  which  is  repeated  every  one, 


GONOCOCCAL  CHRONIC  URErillilTIS  295 

two  or  three  days  aecording  to  reaction.  Improvement  requires  longer 
interval  and  greater  strength  of  medication  but  never  up  to  irritation. 
One  in  15,000  to  1  in  10,000  or  1  in  5000  of  the  zinc  and  alum  astringent 
followed  by  1  in  10,000  to  1  in  5000  potassium  permanganate  and  next 
by  nitrate  of  silver  solution  of  the  same  strength  is  the  best  sequence. 
Of  less  value  is  the  reflux  catheter  because  in  the  posterior  urethra  it  is 
difficult  to  prevent  slight  spasm  of  the  compressor  urethras  muscle 
which  confines  the  fluid  unduly  and  sometimes  leads  to  chemical  irri- 
tation and  then  infection  of  the  prostate  and  seminal  vesicles.  Its 
size  should  always  be  small  and  the  fluids  begun  at  lower  strengths 
than  those  specified. 

Ointment  Soimds.— The  best  are  Young's^  and  the  author's.^  Their 
features  are  shown  in  Fig.  71 ,  which  gives  from  left  to  right  the  plunger 
and  shaft  of  the  Young  instrument,  without  detailing  the  lateral 
outlet.  The  curved  sound,  inner  sheath  and  hard  rubber  container 
and  expression  screw  of  the  Pedersen  apparatus  are  clear.  The  sheath 
within  the  sound  delivers  ointment  near  the  outlet  and  permits  boiling 


Fig.  71. — The  ointment-applicating  sound. 

the  sound  with  little  grease  in  the  water  to  coat  other  instruments. 
Disadvantages  of  ointments  are  that  the  urethra  is  not  strictly  absorb- 
ent as  the  skin  is,  and  that  moisture  and  mucus  further  prevent  action 
of  salves  safe  on  mucous  membranes. 

For  instillations  the  soft  or  hard  instrmnent  may  be  used,  with  prefer- 
ence for  the  former  in  the  early  periods,  when  the  mucosa  is  apt  to  be 
irritable,  and  for  the  latter  in  the  later  stages,  when  the  lining  is  indolent 
and  relaxed  or  infiltrated.  The  instruments  are,  therefore,  a  syringe 
and  soft  catheter,  the  Keyes-Ultzmann  syringe  or  the  Bangs  sjrringe 
sound  and  treatments  are  repeated  every  one,  two  or  three  days  of 
ascending  strengths  of  silver  nitrate  solution  1  in  1000  to  1  in  100,  with 
only  a  few  drops  at  a  time  especially  of  the  higher  percentages.  The 
syringe-and-catheter  method  requires  the  Hayden  or  other  s;vTinge  and 
a  soft-rubber  velvet-eye  catheter  No.  16  to  20  French  passed  into  the 
deep  urethra,  where  it  leaves  its  deposit  of  medicine.  The  Keyes- 
Ultzmann  sja-inge  (Fig.  72,  1)  is  passed  like  a  sound  untU  it  reaches 

1  Tr.  Am.  Urol.  Assn.,  190S,  ii,  73. 

2  Pedersen,  V.  C:  Med.  Rec,  May  30,  1908. 


296 


CHRONIC  URETHRITIS 


the  vertical  position  with  the  patient  rccimibent  when  it  discharges 
the  drug  into  the  ])rostatic  urethra.  The  Bangs  syringe  sound  (Fig. 
72,5)  is  also  used  like  a  sound  in  the  reclining  i)osition  of  the  ])atient. 
Its  tip  is  in  the  posterior  urethra  when  its  shaft  is  vertical  to  the  table. 
The  medicine  is  then  delivered  upon  the  mucosa.  This  instrument  has 
the  advantage  of  a  full  assortment  of  ti])s  in  the  French  lu'cthral  scale 
so  that  a  selection  for  begiiniing  the  instillation  and  for  continuing 
it  in  combination  with  dilatation  nun*  rcadiK'  be  nuuU'.    In  tlic  author's 


hA 


} 


T 


r 


%r  ^ 


Fig.  72. — Posterior  urethral  syringes.  1,  Ultzmanu  syringe  (Kej-es  pattern),  modern 
metal  form,  with  removable  screw-joint  tip,  in  contrast  with  the  original  hard-rubber 
form  vAih  fixed  tip;  2,  glass  barrel  and  plunger,  slip-joint  modification  of  the  Ultzmann 
syringe;  3,  Bangs's  syringe  sound,  with  assorted  sizes  of  slip-joint  tips;  size  13  Fr. 
assembled  ■nith  the  syringe  is  shown;  4,  Bangs's  syringe  sound,  24  Fr.  tip  separated 
from  the  syringe  and  shoeing  the  long,  ground  huh;  5,  author's  hub  for  employing  any 
sjTinge  for  the  Bangs  sounds,  with  standard  screw  for  the  syringes  and  standard  hub 
for  the  tips. 

opinion  it  is  the  best  of  the  three  methods  in  skilled  hands.  Instilla- 
tions in  ordinary  cases  begin  with  siher  nitrate  solution  1  in  5000  and 
ascend  to  1  in  1000  or  1  in  ")()(),  but  where  the  mucosa  is  more  damaged 
and  tendency  or  actuality  of  prostatitis  and  seminal  vesiculitis  is  present 
smaller  quantities  of  greater  concentrations  are  allowable,  1  in  500  to 
1  in  125  preferably  with  the  soft  catheter  especially  at  first. 

Dilatation  is  gentle  increase  in  the  size  of  instruments  used,  never 
with  unfavorable  reaction,  such  as  bleeding,  pain,  fever  or  prostration, 


GONOCOCCAL  CHRONIC  URETURJTfS 


297 


beginning  after  other  symptoms  except  chronic  drop  and  shreds  and 
failure  of  response  to  treatment  have  ceased.  It  requires  the  pre- 
liminary passing  of  urine  or  washing  of  the  anterior  canal,  then  flexible 


Fi&.  73. — Instillation  of  the  prostatic  urethra.  The  Bangs  syringe  sound  has  been 
passed  to  the  step  of  elevation  (as  in  the  steps  of  passing  a  sound,  see  Fig.  64).  The  left 
hand  supports  the  penis,  urethra  and  sound,  while  the  right  hand  evacuates  the  syringe. 
(Original.) 


Fig.  74. — Retained  instillation  of  the  prostatic  and  bulbous  urethra.     The  largest 
painless  size  of  Bangs's  syringe  sound  has  been  passed,  the  deep  urethra  has  been  instil- 
lated  and,  during  slow  withdrawal  of  the  sound,  the  bulbous  urethra  has  been  treated. 
The  injection  is  retained  a  few  moments  by  leaving  the  instrument  at  rest  on  the  abdomen. 
(Original.) 


29S  CHRONIC  URETHRITIS 

or  metal  instruments  in  the  form  of  standartl  sounds,  Benique's  sounds, 
the  author's  irrigating  or  ointment  sounds  and  KoUmann  dihitors. 

In  tlie  earlier  ])eriods  the  flexible  instruments  are  preferred  until 
about  24  Freneh  is  reaehe<l,  when  steel  instruments  are  better.  If 
irrigation  is  desired  with  the  flexible  lisle-thread  instrimients  a  catheter 
may  be  momited  on  a  Avoven  sound  as  its  obtm'ator,  passed  into  the 
bladder  and  then  freed  of  the  soun<l,  thus  permitting  treatment  of  the 
bladder  and  iilling  it  for  the  retrojection  as  diseussed  elsewhere.^ 
After  eleansing  the  meatus  and  lubrieating  the  sound  it  is  engaged  in 
the  meatus  and  anterior  urethra,  where  supported  by  the  hand  it  is 
slightly  bent  in  order  to  facilitate  passing  the  membranous  urethra. 
After  this  step  it  is  passed  directly  into  the  bladder  with  the  penis 
held  horizontally,  as  its  flexibility  permits  it  to  follow  the  curves  of  the 
urethra  without  other  manipulation. 

The  method  of  passing  metal  sounds,  illustrated  in  Figs.  98-102, 
consists  of  five  steps:  gra\itation,  elongation,  elevation,  depression  and 
penetration.  In  gravitation  the  sound  by  its  own  weight  enters  the 
meatus  and  anterior  lu-ethra  while  both  are  held  in  the  middle  line  of  the 
body.  Still  in  this  general  position,  elonc/ation  of  the  penis  over  the 
sound  as  far  as  possible  is  performed,  which  usually  carries  the  tip  of 
the  instnmient  almost  to  the  bulb,  also  of  its  own  weight.  Elevatio7i 
of  the  handle  to  the  vertical  position  now  carries  the  tip  of  the  instru- 
ment tlu-ough  the  bulb  and  into  the  membranous  urethra,  especially 
if  the  instrmiient  is  made  to  hug  the  roof  of  the  canal  by  support  upon 
the  perineal  body  with  the  other  hand  or  by  slightly  pulling  the  instru- 
ment upward  or,  in  difficult  cases,  with  the  finger  in  the  rectum  as  a 
guide.  Depression  of  the  handle  in  the  middle  line  of  the  body  now 
carries  the  tip  of  the  instriunent  up  to  and  through  the  sphincter  at 
about  the  time  when  the  shaft  of  the  sound  is  parallel  with  the  table. 
Penetration  is  now  performed  by  pushing  the  sound  du-ectly  into  the 
bladder  as  far  as  possible  without  pain  and  rotating  it  gently  there  to 
pro\e  its  proper  position  of  the  curve  within  the  bladder  and  the  shaft 
within  the  m-etlira.  In  none  of  these  steps  does  the  sound  leave  the 
middle  line  of  the  body  and  all  the  indirect  and  twisting  movements 
of  reaching  the  bulb  often  described  are  so  useless  as  to  be  foolish. 
Exactly  the  same  steps  are  followed  in  passing  cystoscopes,  the  cysto- 
urethroscope,  straight  sounds,  the  Kollmann  dilators,  metal  catheters, 
stone  searchers,  stone  crushers,  or  any  other  urethral  or  bladder  instru- 
ments. 

For  m-ethral  retrojection  the  author's  irrigating  sounds  are  described 
on  page  370.  As  shown,  one  penetration  with  these  instruments  per- 
mits washing  the  bladder  and  filling  it  with  fluid  for  evacuation  and 
retrojection.  If,  on  the  other  hand,  irrigation  is  desired,  then  the  Koll- 
mami  irrigating  dilator  is  called  for,  as  described  under  Anterior  Chronic 
Urethritis  on  page  287,  and  the  current  maintained  into  the  bladder 
and  back  through  the  urethra.    The  mstillating  sounds  are  described 

*  Pedersen,  V.  C. :  Loc.  cit. 


GONOCOCCAL  CHRONIC  URETHRITIS  299 

under  instillations  in  the  previous  paragraphs  and  the  Han^^s  forni  of 
instrument  is  best. 

The  cupped  soimds  have  cups  in  their  shafts  for  applying  ointments 
to  the  urethra,  such  as  5  ])er  cent,  nitrate  of  silver  or  argyrol  in  lanolin. 
The  cups  should  be  small,  with  smooth  margins  to  avoid  irritation  and 
deep  to  hold  sufficient  ointment,  whose  melting  point  must  be  low  so 
that  during  retention  it  will  reach  the  mucosa. 

The  author's^  ointment  sound  depicted  in  Fig.  71  is  a  more  reliable 
method  of  applying  this  treatment.  It  consists  of  a  silver  outside  tube 
shaped  like  a  sound  with  an  end  opening,  into  which  slips  the  inner 
sheath  carrying  the  ointment  to  the  base  of  the  short  curve.  By  screw- 
ing the  handle  together  the  salve  is  forced  into  the  urethra.  Removal 
of  the  handle  and  sheath  permits  boiling  the  tip  with  loss  of  little  salve. 
Several  handles  and  sheaths  each  containing  a  different  ointment  are 
necessary.  The  watery  element  of  the  mucus  and  of  the  mucosa  itself 
largely  prevents  the  absorption  of  ointments  and  the  action  of  the  plug 
of  salve  as  a  foreign  body  causes  not  only  an  outpom-ing  of  mucoserum 
but  also  muscular  action  for  its  expulsion.  Greasy  fluids  in  the  urethra 
are  therefore  a  failure. 

Straight  sounds  in  the  anterior  luethra  are  usually  employed,  because 
their  length  just  reaches  the  bulb  of  -the  urethra  and  does  not  invade 
the  posterior  urethra.  The  curved  sound  may  be  used  if  the  urologist 
stops  with  the  second  step  of  elongation  described  by  the  author  in 
the  technic  of  passing  these  instruments  in  Fig.  97.  The  tip  of  the 
curve  is  then  in  the  bulb  ready  for  the  massage  if  desired  or  for  with- 
drawal after  the  dilatation. 

The  Kollmann  dilators  of  the  nonirritating  and  irrigating  tjpe  are 
valuable  instruments  and  discussed  under  Anterior  Chronic  Urethritis, 
The  irrigating  form  is  the  most  serviceable  because  one  may  use  it 
without  or  with  fluid,  the  straight  instriunent  for  the  anterior  and  the 
curved  form  for  the  posterior  luethra.  Their  insertion  is  spoken  of 
on  page  376.  The  irrigation  may  involve  the  bladder  alone  or  include 
the  luethra. 

Surgical  methods  are  nonoperative  or  operative,  of  which  the  former 
are  chiefly  comprised  in  the  technics  already  covered,  leaving  the  opera- 
tive means  which  include  urethroscopy  and  cystom-ethroscopy.  Cystos- 
copy is  performed  as  a  routine  diagnosis  of  the  bladder  in  posterior 
chronic  m"ethritis. 

Urethroscopy  is  fully  discussed  in  Chapter  XII  on  page  616,  but 
finds  an  important  activity  in  chronic  posterior  urethritis  whose  lesions 
involve  the  mucosa  as  a  whole  from  the  membranous  m'ethra  up  to 
and  even  into  the  bladder,  including  the  mucous  cr^'pts  and  foUicles 
of  the  membrane  and  in  complicated  cases,  to  be  described  later,  the 
ducts  of  the  prostate  and  testicles  emerging  in  this  portion.  Every 
possible  change  in  the  mucosa  due  to  penetrating  inflammation  is 
found  and  may  be  advisedly  treated  through  the  urethroscope  with 

^  Pedersen,  V.  C:    Loc.  cit. 


300  CHROMC  VRETHRITrS 

direct  ai)]>lic'ations  of  antiseptic,  astringent,  st^']3tie  and  even  caustic 
solutions,  and  of  stinuilating  and  cauterizing  strengtlis  of  the  high- 
frequency  ciurent  of  Oudin  and  of  directly  surgical  procedures  in  sharp 
and  blunt  curetting  and  incision.  The  lesions  thus  treated  are  (1) 
exfoliation  shown  l)y  loss  of  normal  gloss  of  the  nuicosa  re([uiring  mild 
astringent  and  i)ossibly  antiseptic  medication;  (2)  erosions  reaching 
the  deeper  layer  of  epithelia  and  indicating  mild  caustic  stimulation 
and  at  times  blunt  or  sharp  curettement;  (3)  ulcerations  which  are 
the  next  destructive  ])rocess  and  relieved  ])y  slightly  more  energetic 
treatment  of  the  same  kind  with  light  fulguration  addeil;  (4)  exuberant 
granulations  are  the  first  producti^•e  lesions  and  need  reduction  with 
the  caustics,  ciu'ette  and  stronger  high-frequency  ciuTent;  (5)  granulo- 
mata  as  the  further  development  of  exuberance  and  ((>)  papillomata  as 
true  new  growths  both  recpiirc  removal  with  the  Oudin  current  at  one 
or  more  sittings.  In^■asion  of  the  mucous  crypts  and  follicles  is  a  com- 
plication whose  treatment  is  discussed  under  that  heading.  The  indi- 
vidual technic  of  all  these  treatments  is  shown  in  the  Chapter  XII 
on  I  rethroscopy. 

Cystoin-ethroscopy  permits  treatment  of  the  neck  of  the  bladder 
over  the  sm-face  covered  by  the  folds  of  the  mucosa  o^'er  the  muscle 
and  of  the  cervical  portion  of  the  viscus  in  the  author's^  subdivision 
of  the  cavity.  With  the  instrument  in  place  the  ureterotrigonal  and 
subperitoneal  quadrants  may  be  satisfactorily  examined  with  the 
lU'eters  in  verification  of  absence  of  infection.  Lesions  of  any  of  the 
foregoing  types  are  treated  on  the  principles  stated. 

Cystoscopy  should  be  done  if  there  is  any  suggestion  that  the  bladder 
as  a  whole  has  been  invaded,  as  the  earlier  the  treatment  the  surer  the 
result  in  bladder  work.  The  cystoiu-ethroscope  will  reach  only  the 
fiow^  and  not  the  urachal  and  retropubic  quadrants. 

Irrigation  Method;  General  Principles. — As  in  anterior  and  posterior 
acute  and  chronic  m-ethritis,  the  irrigation  treatment  has  its  applica- 
tion and  a(hocates,  but  in  the  last  analysis  it  really  is  retrojection 
because  in  both  the  ^'alentine-Janet  and  the  Chetwood  double-current 
method  the  sphincter  is  overcome  by  pressure  of  the  stream  of  irri- 
gating fluid  until  the  bladder  is'washed  and  distended,  after,  of  course, 
preliminary  cleansing  of  the  anterior  urethra  and  urination  by  the 
patient.  In  the  syringe  and  catheter  method  following  the  same 
introductory  steps  the  catheter  enters  the  bladder,  which  is  again 
washed  and  filled  ready  for  the  patient  to  retroject  his  own  canal 
under  Natiu-e's  pressm'e  during  urination.  With  the  Kollmann  irri- 
gating dilator  perhaps  the  truest  irrigation  is  reached,  because  with  the 
cur\'ed  instrument  in  the  posterior  urethra  and  bladder,  gently  dilated 
and  holding  the  two  organs  open,  the  irrigating  fluid  flows  into  the 
bladder  and  out  again.  In  this  method,  however,  retrojection  may  also 
be  the  last  step  by  filling  the  bladder  before  the  instriunent  is  with- 
drawn.    In  review,  therefore,  this  part  of  the  irrigation  treatment 

'Pedcr.sen,  V.  C:    Loc.  cit. 


NONGONOCOCCAL  CHRONIC  URETHRITIS  301 

becomes,  as  already  shown,  an  adaptation  of  the  cons(;rvative  nietlifKl 
which  may  therefore  be  regarded  as  in(;hiding  the  irrigation  teclinic, 
as  far  as  the  posterior  urethra  is  concerned. 

Cure. — Cure  in  the  posterior  urethra  involves  all  th(!  cautions  of 
those  laid  down  for  the  anterior  urethra  with  greater  emphasis  because 
the  primary  sexual  glands  or  testes  with  their  ducts  and  the  secondary 
sexual  gland  or  prostate  with  its  ducts  all  deliver  their  secretions  into 
this  part  of  the  canal.  The  tendency  of  the  gonococcus  to  affect  these 
outlets  along  with  the  mucosa  as  a  whole,  although  there  may  be 
no  complications  resulting  in  the  strict  sense,  requires  the  most  careful 
analysis  on  repeated  occasions  before  a  final  certificate  of  health  is 
possible.  Therefore  the  secretions  of  these  glands  must  be  obtained 
by  careful  massage  and  stripping  of  the  seminal  vesicles  and  ampullfe 
of  the  vasa  deferentia  and  of  the  lateral  and  middle  lobes  of  the  pros- 
tate. This  will  often  suffice  to  furnish  specimens  in  proof  of  present 
or  absent  infection.  A  better  test  in  the  author's  opinion  is  to  have 
the  patient  wear  a  condom  at  night  until  after  a  few  times  a  seminal 
emission  occm-s  which  prociu"es  a  specunen  under  sexual  excitement, 
which  is  exactly  the  circumstance  in  which  hidden  gonococci  show 
themselves.  Such  organisms  are  the  most  treacherous  in  diagnosis 
and  treatment.  Smear  and  culture  bacteriology  must  be  carried  out 
and  the  gonococcal  complement  fixation  test  must  never  be  omitted, 
because  the  chronicity  and  absorptive  tendencies  in  the  deep  urethia 
increase  its  frequency  and  reliability. 

2.  NONGONOCOCCAL  CHRONIC  URETHRITIS. 

Varieties. — Exactly  as  in  gonococcal  lesions,  the  nongonococcal  infec- 
tions vary  as  to  location.  Anterior,  posterior  and  anteroposterior  are 
recognized.  Those  as  to  source,  as  given  in  the  clinical  portion  of  this 
work,  are:  catarrhal,  diathetic,  suppurative,  sjq^hilitic,  chancroidal, 
herpetic  and  traumatic. 

Clinical  Features. — The  etiology,  pathology,  symptoms  and  diagnosis 
are  included  in  the  Chapters  on  Acute  Urethritis  and  that  on  the  Com- 
plications of  Acute  Urethritis  for  more  definite  contrast  with  the  clinical 
facts  of  gonococcal  urethritis.  Similarly,  here  in  this  chapter  the  treat- 
ment of  these  two  general  forms  of  urethritis  are  considered  side  by 
side  for  emphasis. 

General  principles  are  the  same  as  those  laid  down  for  the  treatment 
of  gonococcal  m-ethritis  with  regard  for  the  periods  of  the  disease,  for 
gentleness  and  caution  rather  than  energy  and  abandon. 

Anterior  and  Posterior  Catarrhal  Acute  and  Chronic  Urethritis. — 
Varieties. — These  are  concerned  with  primary  and  secondary  cases. 
Primary  infections  concern  us  here  because  the  other  form,  sec- 
ondary, is  seen  diu-ing  the  invasion  and  during  the  termination  of  other 
types. 

Treatment. — Preventive  and  abortive  treatments  in  catarrhal  sub- 
jects require  good  health,  elimination,  exercise,  suitable  diet  and  avoid- 


302  CHROXIC  URETHRITIS 

ance  of  any  local  irritation  in  terms  of  food,  drink  or  sexnal  indul,i::onoe. 
Some  eases  depend  alone  on  the  latter  throuj;h  excesses  and  i)erversions. 

Curative  Treatment. — The  relief  depends  on  the  sym])tomatie  and 
the  patholoiric  indications.  The  local  s\iTiptoms  are  milder  in  degree 
but  similar  in  kind  to  the  gonococcal  tyjies  and  are  relic^•ed  by  the  same 
though  gentler  means  and  often  with  less  frequent  repetition,  while 
the  systemic  symptoms  are  absent  unless  the  allied  catarrhs  in  patients 
of  this  type  show  their  own  symptoms.  The  indication  is  therefore 
the  same  as  in  gonococcal  disease  graduated  to  meet  these  facts  in 
primary  catarrhal  urethritis.  jNIany  secondary  cases  are  the  terminal 
stages  of  more  severe  lesions  and  their  treatment  is  found  under  such 
lesions. 

Cure. — Cure  requires  restoration  of  the  nuicosa  to  a  normal  state 
without  catarrhal  lesion  or  discharge.  An  absolutely  nonbacterial 
condition  cannot  be  attained  on  account  of  the  normal  flora  of  the 
urethra.  Relapses  of  the  local  condition  rest  on  the  systemic  catarrhal 
tendency  which  must  therefore  be  ]iart  c^f  the  ciu*e. 

Anterior  and  Posterior  Diathetic  Acute  and  Chronic  Urethritis.^ 
Treatment. — Preventive  and  aborti^■e  treatments  resohe  themselves 
into  that  of  the  gout,  rheumatism,  eczema  and  intestinal  toxemia 
with  constipation  common  in  these  individuals.  As  in  catarrhal 
urethritis  improvement  is  necessary  in  health,  strength,  digestion  and 
elimination  for  prevention.  Reduction  or  omission  of  nitrogenous 
food  of  all  types  is  at  least  temporarily  essential.  Abortion  in  the 
exact  meaning  of  the  term  is  not  possible. 

Required  study  of  management  is  provided  in  Chapter  IX  on  General 
Principles  of  Treatment. 

The  physical  measures  are  \'ery  important.  When  exercise  cannot 
be  had,  vigorous  massage  is  a  good  substitute  aided  by  body  baths,  hot 
packs,  Tiu-kish  or  Russian  baths  in  the  hydrotherapy  for  cutaneous 
excretion.  Elimination  is  greatly  stimulated  by  electrotherapy,  espe- 
cially the  d'Arsonval  high-frequency  current  employed  by  the  auto- 
condensation  method  and  general  bodily  and  nervous  vigor  are  restored 
by  the  static  wave  current  method  with  a  long  positive  electrode  over 
the  spine  and  the  negative  pole  grounded. 

The  medicinal  measures  embrace  all  drugs  against  so-called  hyper- 
acidity- ])>•  systemic  admiiiistration.  The  lu'ine  must  be  made  and  kept 
bland  with  j^lain  or  mineral  water,  bicarbonate  of  soda  in  large  doses 
or  other  alkalies.  Nitrogenous  elimination  must  be  stimulated  and 
faulty  assiiuilation  corrected  by  buttermilk  diet  or  products  or  the 
lactic  acid  organisms  gi\'en  with  or  without  the  milk.  Local  treatment 
is  the  same  as  that  for  catarrhal  urethritis  if  the  ^licrococcus  catarrhalis 
is  present  or  the  same  as  that  for  pyogenic  urethritis  if  the  pus-producing 
organisms  have  been  isolated.  Otherwise,  as  a  rule,  there  is  little  treat- 
ment of  the  mucosa  except  the  indirect  benefit  derived  from  attention 
to  the  luulerlyiiig  diathesis,  the  urine  and  the  hygiene,  as  stated.  In 
more  marked  case  the  measures  recommended  for  prunary  catarrhal 
urethritis  are  commended. 


NONGONOCOCCAL  CHRONIC  URETHRITIS  303 

Anterior  and  Posterior  Pyogenic  Acute  and  Chronic  Urethritis. — 
Treatment. — Preventive  treatment  is  tlie  tuialoKne  of  thiit  in  ^oiux-oc.c.a] 
urethritis,  and  only  tentative  measnn^s  in  refined  treatment,  earefnl 
diagnosis  and  faitliful  obedienc;e  to  orders  hy  the  patient  may  avail. 
Asepsis  in  the  passing  of  instruments  with  irrigation  of  the  urethra 
previously  and  subsequently  is  important  when  pyogenic  organisms 
are  known  to  be  in  the  canal.  The  author's  irrigating  sounds  are  most 
important  in  this  relation.  There  are  no  means  of  abortitjn  in  the  true 
sense,  except  continuation  of  the  irrigations  during  the  presence  of  any 
signs  of  incubation  or  invasion. 

Management  is  completely  described  in  its  requisites  in  Chapter  IX 
on  General  Principles  of  Treatment. 

Curative  Treatment. — The  cure  depends  on  the  same  principles  as 
gonococcal  urethritis.  The  local  and  systemic  symptoms  are  the  same 
in  nature,  and  often  in  degree  as  those  of  gonococcal  urethritis  with  no 
means  of  distinction  except  the  microscope.  Quite  frequently  the 
pyogenic  organisms  are  associated  with  the  gonococcus  and  their 
growths  is  so  exuberant  as  to  hide  the  latter  in  the  florid  period.  The 
varieties  of  organism  are  fully  explained  in  the  paragraphs  on  etiology 
on  page  21.  The  pathologic  and  symptomic  indications  virtually 
duplicate  those  of  gonococcal  manifestations. 

The  physical  measures  are  exactly  the  same  as  those  described  for 
the  parallel  gonococcal  infections  as  to  massage,  hydrotherapy,  and 
electrotherapy,  both  local  and  general,  in  both  anterior  and  posterior 
acute  and  chronic  manifestations.  The  reader  is  referred  to  the  para- 
graphs on  these  subjects,  in  previous  chapters. 

The  medicinal  measures  both  by  systemic  and  local  exhibition  are 
the  same  as  in  gonococcal  inflammation  but  the  serumtherapy  varies 
slightly  in  that  autogenous  or  stock  bacterins  of  the  predominating 
organism,  such  as  the  bacillus  coli,  for  example,  or  autogenous  mixed 
bacterins  containing  all  the  flora  of  the  case  or  the  stock  mixed 
bacterium  of  Van  Cott  may  be  tried  often  with  greater  advantage 
because  the  latter  contains  the  gonococcus  which  is  occasionally  present 
but  overgrown  by  its  associates.  Similarly  the  gonococcal  comple- 
ment fixation  test  in  severe  and  prolonged  cases  will,  if  positive,  give 
proof.  Local  administration  is — by  the  expectant  and  irrigating 
methods — irrigations,  injections,  retrojections  and  instillations  pre- 
ferably during  the  period  of  decline  and  thereafter,  and  followed  by 
applications  with  the  urethroscope  in  the  period  of  termination.  All 
the  methods  and  medications  are  the  same  as  in  gonococcal  invasion, 
likewise  surgical  details,  such  as  mild  dilatation  wdth  soft,  flexible  or 
metal  sounds,  the  author's  irrigating  sounds,  the  Bangs  instillation 
sounds  and  the  Kollmann  irrigating  dilators.  Instnmientation  is 
postponed  until  the  infiltration  stage,  if  present.  In  this  disease,  there- 
fore, the  stages,  means  and  drugs  of  treatment  and  the  frequency  of 
visits  are  all  correlative. 

Cure. — Cure  is  the  relief  of  infection  shown  by  smear  and  culture 
and  the  blood  test  to  eliminate  the  gonococcus  as  a  cause. 


304  CHROXIC  URETHRITIS 

Syphilitic  or  Chancrous  Urethritis. — Treatment.  -l^-(>\entive  treat- 
iiU'ut  iii\ol\'es  iiu'asurt's  auaiust  tlu'  inoc-ulation  of  sypliilis  not  in  the 
pro\ince  of  this  work  but  consisting  generally  of  careful  cleansing 
after  intercourse,  followed  by  wet  dressing  and  ointment  during  the 
first  twelve  or  twenty-four  hours.  Thorough  sterilization  of  all  instru- 
ments used  in  comiection  with  sy])hilitics  is  an  essential. 

Aborti\e  treatment  is  not  ])ossil)le,  as  i)roved  by  the  long  and  bitter 
controvei'sy  among  sj'philologists  of  the  passing  generation. 

jManagement  is  completely  descril)ed  in  its  reciuisites  in  rha])ter  IX 
on  General  rrincii)les  of  Treatment. 

Ciinitivc  Trcdfinctif. — The  ])rincii)les  invoh'e  surgical  dryness  and 
cleanliness,  healing  applications  and  systemic  treatment. 

The  electrotherapy  consists  in  fulgurating  the  lesion  to  desiccation 
only  and  not  to  cauterization.  The  spark  gap  is  yV  of  an  inch  and 
the  a])plication  nuist  dry  or  blanch  and  not  burn  the  lesion.  One 
a]i]ilication  is  sufficient  unless  the  chancre  is  a  large  one.  The  static 
machine  of  the  multiple  plate  high-speed  type  is  best  for  producing 
this  current. 

The  medicinal  measures  are  the  intramuscular  injection  of  the  soluble 
or  insoluble  mercm'ial  salts,  the  intravenous  injection  of  salvarsan, 
neosalvarsan  or  cacodylate  of  soda  and  the  ingestion  of  mercury,  or 
arsenic  both  without  or  with  iodid  of  potash  or  iodid  of  soda  to 
tolerance.  Alkaline  mineral  waters  appear  to  aid  metabolism  and 
assimilation  of  the  medicine.  The  urine  should  be  bland  to  stop  irritat- 
ing the  urethritis  and  chancre.  Local  means  are  wet  dressing  or  sah'e 
containing  merciu-y  applied  on  gauze  or  cotton  to  the  lesion,  which  is 
usually  at  the  meatus,  and  frequently  changed  for  cleanliness.  If  the 
chancre  is  intram-ethral,  from  0.5  to  1.0  cm.  up  the  canal,  ointment 
may  be  squeezed  upon  it  through  the  meatus  and  lield  in  place  by  a 
cotton  plug.  After  healing,  the  infiltration  is  resoh'ed  b}'  the  continuous 
application  of  ointment  and  later  by  gentle  dilatation  with  soft  sounds. 

Ciire. — Ciu^e  of  the  chancre  and  the  urethritis  is  not  a  cure  of  the 
syphilis,  which  must  be  prosecuted  along  accepted  lines  with  untiring 
watchfulness  and  judicious  zeal  by  both  physician  and  jjatient,  but 
never  to  the  limit  of  undoing  the  patient's  well-being  or  health  with 
mere  medication. 

Chancroidal  Urethritis. — Treatment. — Preventive  treatment  oftVrs 
nothing  new  over  those  presented  for  both  gonococcal  and  syphilitic 
urethritis,  as  examples,  and  is  equally  successful  when  promptly  and 
properly  carried  out.  Abortive  applications  are  unreliable  except 
perhaps  careful  cauterization  at  the  earliest  possible  sign  of  any 
abrasion  and  its  infection. 

Curative  Treatment.— The  symptoms  and  indications  are  the  factors. 
The  sjTnptoms  are  those  of  ardor  urina?  from  a*  painful  irritating  and 
extending  sore  at  the  meatus  or  just  within  it  with  subsequent  purulent 
exudate  and  even  urethral  discharge  making  the  indications  those  of 
immediate  destruction  of  the  virus,  healing  of  the  sore  and  correction 
of  the  urethritis. 


NONGONOCOCCAL  CHRONIC  URETHRITIS  305 

The  general  methods  are  identical  with  those  for  chancrous  inflam- 
mation except  that  the  exciting  organism  is  the  bacillus  of  Ducrey  and 
requires  slightly  difl'crent  application.  There  are  no  differences  in  cither 
management  or  physical  means  b(;tween  the  two  diseases.  Electro- 
therapy is  fulguration  to  the  coagulation  or  incineration  strength  with 
a  spark  gap  of  a  xV  of  an  inch  applied  to  the  sore  or  sores  until  the 
coagulation  is  apparent.  The  number  of  treatments  is  one  for  small 
lesions  and  several  for  larger  lesions.  The  multiple-plate  high-speed 
standard  static  electrical  machine  produces  the  best  current  for  this 
purpose. 

The  medicinal  measures,  as  the  disease  is  local  only,  offer  no  internal 
measures  such  as  the  blood  test  and  no  administration  of  salvarsan, 
mercury  or  any  other  drug  unless  required  by  the  rare  cases  of  great 
absorption.  The  local  treatment  of  the  chancroid  at  the  meatus  means 
penile  baths  in  hot  antiseptics,  of  which  potassiiun  permanganate  1  in 
2000  to  1  in  1000  is  best  in  the  author's  opinion,  associated  with  wet 
dressings  of  it  on  gauze  or  cotton  or  with  a  paste  of  crystals  or  argyrol 
held  in  and  upon  the  lesion  with  a  dressing.  Black  wash  (U.  S.  P.) 
is  also  a  valued  wet  dressing  in  full  strength.  Mild  caustics  may  be 
cautiously  applied  protecting  the  canal  with  a  plug  of  cotton  from 
leakage  into  it.  The  slough  is  curetted  off  and  the  same  caustic  in 
astringent  strength  immediately  reapplied  to  sterilize  the  new  surface. 
This  method  requires  local  anesthesia  with  a  few  crystals  of  cocain  or 
its  derivatives  dissolved  in  the  exudate  for  five  or  ten  minutes.  The 
use  of  caustic  and  curette  is  frequently  amazingly  successful  but 
requires  skill  and  judgment.  Stenosis  after  healing  requires  dilatation 
with  soft  sounds  or  a  meatotomy  or  an  internal  urethrotomy  according 
to  the  situation  and  the  density  of  the  scar. 

Cure. — Cure  closes  with  healing  without  complications  and  with 
correction  of  the  urethritis.  The  bacillus  of  Ducrey  may  bury  itself 
in  the  lymphatics  and  cause  late  adenitis  in  the  groins,  which  in  turn 
indicates  evacuation  and  drainage  along  surgical  principles. 

Traumatic  Urethritis. — Treatment. — Preventive  treatment  smns  up 
in  good  judgment  in  the  application  of  dilute  solutions,  in  temperate 
heat  or  cold,  in  deliberate  and  gentle  passage  of  all  instruments,  which 
must  be  neither  too  large,  too  hot,  too  cold,  unclean  nor  rough,  in  weak 
currents  and  proper  polarity  of  electricity  and  finally  in  nothing  to 
inflame,  irritate  or  destroy  the  mucosa  even  superficially.  The  abortion 
involves  in  the  presence  of  blood,  pain  or  irritation  in  mild  cases,  simple 
diet,  rest  in  bed,  cold  applications,  mucous  membrane  sedatives  and 
mild  astringent  irrigations  or  retrojections  of  tolerably  hot  nitrate  of 
silver  solution  under  gentle  pressure  and  copious  quantity. 

The  particulars  of  management  are  described  in  Chapter  IX  on 
General  Principles  of  Treatment. 

Curative  Treatment. — The  usual  elements  of  indications  and  symp- 
toms are  present. 

The  medicinal  measures  are  sedatives  to  quiet  the  hemorrhage  and 
pain  by  systemic  administration  in  severe  cases  and  none  is  better  than 
20 


506 


CIIROXIC  URETHRITIS 


a  small  dose  of  iiiorphin  Inixxlennatically.  Locally  hot  irriiijations 
and  retrojections,  at  first  very  dilute  and  of  tolerable  tein])eratiire,  are 
more  iiiiportaut  than  merely  ehemical  action.  There  should  be  no 
application  throuj^h  the  urethroscope  and  no  other  instrumentation 
for  several  da>s  after  the  traumatism  is  relieved,  in  cases  where  it 
arose  during  these  forms  of  treatment. 

Cure. — Ciu"e  is  usually  absolute,  leaving  the  canal  intact  except  for 
tlie  gonococcal  sequel,  which  usually  leads  to  such  incidental  disturb- 
ances. 


Fig.  75. — Author's  ca.se  of  lunar  caustic  traumatic  urethritis.  >SioUt;h  of  the  anterior 
uretlira  of  nearly  natural  size,  caused  by  lunar  caustic  burn.  The  meatus  is  at  the  right 
and  the  deeper  portion  at  the  left  of  the  photograph. 

The  author'  has  reported  a  remarkable  example  of  chemical  trau- 
matic urethritis  from  a  burn  with  lunar  caustic  put  into  the  urethra 
to  abort  a  gonococcal  infection.  This  it  failed  to  do  but  the  slough 
shown  in  Fig.  75  was  cast  at  the  end  of  a  few  days  and  perineal  drainage 
of  the  bladder  was  necessary  to  avoid  infection  of  it.  Dense  stricture 
of  about  22°  F.  was  the  end-result. 


1  Pedersen,  V.  C:  Tr.  Am.  Urol.  Assn.,  1912,  vi,  104  to  106. 


chaptp:r  v. 

COMPLICATIONS  AND  SEQUELS  OF  CHRONIC 
URETHRITIS. 

General  Considerations. — As  stated  in  the  Chapter  on  Complica- 
tions of  Acute  Urethritis,  the  gonococcal  and  other  pyogenic  infections 
are  the  most  severe,  prone  to  have  acute  complications,  to  become 
themselves  chronic  and  to  be  followed  by  the  same  complications  in 
chronic  type.  This  law  is  essential  to  the  nature  of  the  disease  and  the 
delicacy  of  the  tissues  attacked  and  to  their  relatively  slight  recupera- 
tive powers,  as  a  mucosa  once  deeply  damaged  never  fully  restores 
itself. 

One  fact  concerning  chronic  complications  is  that  they  in  them- 
selves are  often  the  sole  cause  of  the  persisting  symptoms.  Thus  in  a 
certain  sense  a  diagnosis  of  chronic  urethritis  is  often  given,  whereas 
in  reality  the  urethra  has  recovered  but  one  of  its  annexa  is  still  in  a 
state  of  chronic  lesions.  It  was  not  until  the  urethroscope  was  thor- 
oughly developed  that  these  details  were  appreciated,  and,  on  the  other 
hand,  a  chronic  complication  may  keep  the  urethritis  frequent  in  its 
relapses,  exacerbations  and  extensions.  For  this  reason  also,  the 
importance  of  full  exploration  for  such  complicating  foci  is  obvious. 

For  the  purposes  of  this  w^ork  a  complication  may  be  regarded  as  a 
condition  arising  during  the  course,  more  or  less  in  virtue  and  with  the 
essential  cause  of  the  primary  process.  A  sequel,  on  the  other  hand, 
is  the  result  of  the  primary  process  after  the  latter  has  clinically  ceased 
as  a  disease  condition.  In  m'olog}'  no  example  of  a  sequel  is  better 
than  strictm"e. 

Definitions. — Unless  otherwise  stated,  the  definition  of  individual 
chronic  lesions  is  the  same  as  that  given  under  the  acute  forms  with  the 
sole  element  of  chronicity  added. 

Similarly,  the  clinical  description  of  the  chronic  complications  is 
based  on  and  abbreviated  from  that  of  the  acute  varieties,  for  the  sake 
of  space.  Thus  full  comprehension  involves  knowledge  of  both  acute 
and  chronic  manifestations. 

General  Clinical  Features. — Chronic  complications  may  occur  dur- 
ing chronic  urethritis  of  Siuy  form,  catarrhal,  diathetic,  nongonococcal, 
pyogenic  and  gonococcal,  and  all  resemble  each  other  closely,  but  the 
last  is  by  far  the  most  common  and  typical,  and  the  others  are  found 
usually  in  nonresistant  soil  and  subjects.  As  previously  m  this  work, 
therefore,  the  gonococcal  will  be  taken  as  the  t;s-pe,  with  the  natural 
subdivisions  into  complications  of  anterior  and  posterior  chronic 
urethritis. 


308  co^rPLICATIOxs  axd  sequels  of  ciinoxic  urethritis 

Varieties. — As  just  stated,  the  anatomical  forms  as  to  location 
arc  anterior  antl  posterior,  and  as  to  distribution  systemic,  of  the 
bodily  economy  at  large,  and  local,  or  urogenital,  of  the  sexual  and 
urinary  tyjics.  Chronic  comjilications  of  the  anterior  urethra,  like  the 
acute,  rarely  have  true  systemic  manifestations  but  tiie  reverse  obtains 
in  tlie  posterior  portion  of  the  canal,  under  which  heading  they  will 
be  discussed.  The  local  complications  are  essentially  sexual  and  include 
the  same  list  as  stated  under  Acute  Com])lications:  that  is,  ])himosis, 
para])himosis,  lymj^hangeitis,  lymj^hadenitis,  littritis,  folliculitis, 
cowperitis  with  retention  and  cowjjcritis  without  retention. 

COMPLICATIONS  OF  ANTERIOR  GONOCOCCAL  CHRONIC 
URETHRITIS. 

A.  Urogenital  Gijoup. 
1.  Sexual  Forms. 

There  is  strictly  no  urinary  group  of  complications  in  anterior 
chronic  urethritis. 

CHRONIC  PHIMOSIS  AND  PARAPHIMOSIS. 

Significance,  Occurrence  and  Etiology  are  much  tlie  same  as  given  on 
pages  So  and  S4.  The  condition  is  due  to  balanoposthitis  from  mixed 
infection  and  the  relapses  of  the  urethritis.  The  irritation  of  chronic 
discharge,  excoriation  of  dressings  and  the  overstimulation  of  applica- 
tions are  factors. 

Pathology. — Pathology  is  definitely  included  under  this  heading  in 
Chajiter  II  on  Complications  of  Acute  Urethritis  on  page  83. 

Symptoms. — Subjecti^'e  and  objective  symptoms  are  as  already 
described  with  the  change  that  the  patient  is  rarely  free  of  trouble 
with  his  glans  and  foreskin.  There  is  almost  always  excess  of  moistiu'e 
and  smegma  with  relapses  of  the  acute  sjonptoms  with  or  without 
parallel  relapses  of  the  urethritis. 

Diagnosis  and  Treatment. — For  the  sake  of  bre\'ity  and  correlation 
lK)tli  these  topics  are  discussed  under  Acute  Diimosis  in  Cha])ter  II, 
on  Complications  and  Secpiels  of  Acute  Urethritis  on  pages  84-G. 

CHRONIC  OR  RELAPSING  BALANITIS,  POSTHITIS  AND 
BALANOPOSTHITIS. 

Definition. — The  modified  skin  over  the  glans  and  within  the  foreskin 
is  susceptible  to  the  same  sites  of  chronic  inflammation  as  in  acute 
disease  and  receives  the  same  terminology. 

Varieties. — Varieties  duplicate  those  seen  in  acute  involvement  to 
^^■hi(•h  the  reader  is  referred.  The  important  forms  are  as  to  foreskin, 
retractible  and  irretractible  and  as  to  course  slowly  progressing  with 


BALANITIS,  rOSTIffTIS  AND  BALANOPOSTIIITIS  309 

little  change  and  relapsiuf,^  with  periods  of  intermission  and  firjaJly 
as  to  infection,  suppurative^  and  gonococcal  and  allied  germs.  Cases 
curable  by  circumcision  and  those  not  modified  by  this  j)rocedure  are 
also  recognized. 

Etiology. — Etiology  is  the  same  as  in  acute  balanitis  an<l  comprises 
malformations  of  the  foreskin,  low  resistance  especially  to  mucosal 
disease  and  the  presence  of  infection  from  chronic  urethritis  and  of 
depression  from  constitutional  disease  like  diabetes.  Upon  the  fav(jr- 
able  soil  thus  prepared  a  low  grade  of  infection  persists  and  progresses 
in  the  persistent  type  or  a  more  active  form  of  involvement  appears 
and  reappears  as  relapses  and  remissions  in  the  relapsing  type. 

Pathology. — Such  persistent  or  relapsing  chronic  inflammation  is  in 
the  essence  of  the  process  the  same  as  similar  lesions  anywhere  else  and 
involves  in  whole  or  in  part  the  modified  skin  covering  the  glans  and 
lining  the  foreskin,  either  superficially  or  deeply,  according  to  age  or 
activity  of  process.  The  tendency  is  toward  thickening,  loss  of  elas- 
ticity and  recurrence  of  discharge.  The  temporary  lesions  are  only 
those  of  the  subacute  process  during  the  exacerbations  while  the  per- 
manent lesions  are  the  chronic  inflammation,  infiltration,  desquamation, 
retraction  and  at  times  deformation  and  compression  of  the  glans  and 
foreskin  through  the  dense  inelastic  skin.  The  associated  lesions  are 
the  natural  abnormality  of  the  foreskin  which  preceded  the  lesion  and 
may  in  turn  be  augmented  by  the  chronic  disease  and  thus  be  both 
cause  and  complication.  The  chronic  urethral  discharge  is  another 
allied  condition  leading  to  fresh  outbreaks  and  sometimes  itself  likewise 
involved. 

Symptoms. — There  is  no  separation  of  the  disease  into  invasion, 
establishment  and  termination  because  invasion  does  not  occur  unless 
as  part  of  each  relapse  and  the  disease  is  ordinarily  without  ending. 
As  in  the  acute  balanitis  there  is  no  systemic  syndrome.  Patients 
complain  of  local  subjective  symptoms,  such  as  intense  itching,  dis- 
comfort, return  of  the  discharge  in  a  relapsing  case  or  continuance  of 
discharge  in  persistent  cases  with  the  usual  soreness  and  odor.  They 
find  the  foreskin  once  retractible  now  irretractible  or  at  best  with 
great  difficulty,  pain  and  fissuring  and  rarely  absence  of  complete 
erection  within  the  glans  proper.  The  objective  symptoms  are  those 
of  chronic  productive  inflammation,  such  as  decreased  vascularity  by 
the  thickening  of  the  skin  and  underlying  tissue,  loss  of  color  from  red 
to  pale  blue,  induration  and  infiltration  from  soft  and  flaccid  to  thick 
and  leathery  condition  under  the  examining  fingers.  The  foreskin  as 
a  whole  may  be  thick,  inelastic  and  leathery,  totally  u'retractible  or 
only  retractible  with  difficulty  and  cracking  along  the  free  margm. 
The  exposed  glans  is  hard  and  dry,  compressed  and  not  set  oft'  from  the 
shaft  of  the  penis  by  a  typical  corona,  which  indeed  may  be  almost 
obliterated.  The  stage  of  termination  is  virtually  absent  as  the  disease 
in  relapsing  cases  may  exist  for  years  without  relief  and  with  little 
serious  damage  beyond  the  slow  sclerosing  process.  Circimicision  may 
cure  such  cases  as  soon  as  performed,  leaving  them  with  the  condition 


310    COMPLICATfOXS  AXD  SEQUELS  OF  CHROXIC  VRErilRlTIS 

fouiul  at  the  time  of  ()])eration;  but  in  tlie  iieulcctod  jjersistont  cases 
tlie  process  goes  on  and  may  even  lead  to  eaneer  of  the  >i;hins  or  fore- 
skin. The  subcutaneous  infiltration  and  thickening;  may  in  any  of 
these  cases  be  felt  between  the  fiuirers  and  must  be  distinuiiished  from 
syphilitic  infectinir  balano])osthitis,  and  early  chancre  or  y-umma  before 
ulceration  and  extension  ai)])ear. 

The  dischar<;e  has  both  fluid  and  detritus  as  elements,  with  the  latter 
predominant.  Compared  witli  the  exudate  in  acute  cases  the  dis- 
chartje  is  much  thicker  because  it  ])rocee(ls  from  a  much  less  active 
process.  The  niodiiied  skin  of  the  cavity  of  the  foreskin  is  macerated 
and  casts  off  shreds,  patches  and  slugs  of  pus,  lea\'ing  behind  indolent 
excoriations  rather  than  active  ulcers.  If  the  cancerous  condition  is 
imminent  then  the  maceration  and  thickening  become  excrescences 
with  ulceration  and  discharge. 

Diagnosis  and  Treatment. — Proper  relations  and  brc\ity  arc  fully 
secured  by  embracing  both  these  subjects  in  Chapter  II  on  Compli- 
cations and  Sequels  of  Acute  Urethritis  on  page  <)(). 

CHRONIC  PREPUTIAL  FOLLICULITIS. 

Definition. — Gonococcal  chronic  infection  of  one  or  more  follicles 
of  the  foreskin  and  glans  comprises  this  disease. 

Etiology. — After  an  acute  folliculitis  one  or  more  of  these  little 
pockets  instead  of  recovery  or  destruction  })asses  into  chronic  inflam- 
mation, with  sinus  and  abscess. 

Pathology. — The  process  is  a  continuation  of  the  acute  lesions  into 
the  chronic  manifestations,  either  as  a  chronic  suppurating  and  dis- 
charging sinus,  or  as  a  follicle  with  its  mouth  occluded,  its  pus  retained 
and  then  discharged,  like  the  spontaneous  evacuation  of  an  abscess. 

Symptoms. — The  pain  of  the  retention,  the  redness  of  the  abscess 
followed  by  the  discharge  or  the  persistence  of  the  discharge  are  the 
subjective  signs,  while  with  the  probe  as  objective  proof  the  discharging 
sinus,  abscess  cavity  or  occluded  outlet  may  be  found  and  with  the 
microsco])e  the  gonococcus  and  its  allies  demonstrated  in  the  pus. 

Diagnosis  and  Treatment. — Repetition  is  avoided  by  inclusion  of 
these  subjects  under  the  acute  lesions  in  Chapter  II  on  Complications 
and  Sequels  of  Acute  Urethritis  on  page  98. 

CHRONIC  PARAURETHRAL  FOLLICULITIS. 

Definition,  Varieties  and  Etiology  are  the  same  as  detailed  under  the 
identical  lesions  comjjlicating  acute  urethritis  on  page  99,  with  the 
sole  factor  of  chronic  elements  added. 

Pathology. — Pathology  is  likewise  the  same  in  its  essence  and  course 
but  without  termination,  in  that  the  lesions  persist.  They  are  in  dis- 
tribution du])licate  of  the  acute  conditions,  unilateral  or  bilateral, 
single  or  multiple,  and  instead  of  reaching  recovery  or  destruction, 
continue  their  process  as  sinuses,  pockets  or  fistula^,  blind  internally, 
opening  externally  and  usually  containing  gonococci. 


GONOCOCCAL  CHRONIC  URETHRITIS  311 

Symptoms. — After  the  acute  stage  has  subsided,  the  subjective  signs 
show  absence  of  full  recovery  and  the  presence  of  constant  or  inter- 
mittent suppuration  and  discharge  in  accordance  with  the  presence  or 
absence  of  occlusion.  Objective  investigation  shows  the  little  sinus, 
pocket  or  fistula  as  already  noted,  and  usually  gonococci. 

Diagnosis  and  Treatment. — Undue  extension  of  this  work  is  prevented 
by  consideration  of  both  these  headings  in  Chapter  II  on  Complica- 
tions and  Sequels  of  Acute  Urethritis  on  page  100. 

CHRONIC  PERIURETHRAL  ABSCESS. 

Definitions,  Varieties,  Etiology  and  Pathology  repeat  those  stated  under 
the  acute  process  on  pages  101  and  102,  but  involve  the  estabhshment 
of  a  chronic  cavity  with  exacerbations  during  or  independently  of 
the  same  periods  of  the  chronic  urethritis. 

Symptoms. — Periods  of  quiescence  and  activity  are  noted  as  in  any 
other  chronic  abscess.  The  subjective  symptoms  during  quiescence  are 
sinus,  pocket  and  constant  discharge,  or  leakage  after  expression  or 
muscular  action,  and  those  during  activity  exemplify  acute  or  subacute 
abscess  with  spontaneous  or  artificial  evacuation,  exactly  as  described 
under  the  acute  complication.  There  is  no  true  termination  in  many 
cases  as  the  disease  may  discharge  throughout  life  or  repeat  the  cycle 
of  acute  attacks.  Infection  may  be  indefinitely  prolonged.  The  objec- 
tive signs  verify  the  foregoing  facts  described  by  intelligent  patients. 
Urethroscopy  in  these  cases  is  very  valuable  but  should  not  be  carried 
out  dm'ing  acute  stages.  The  clinical  importance  of  these  periurethral 
abscesses  cannot  be  overestimated  as  sources  of  infection  of  the  inno- 
cent, by  gonococci  which  may  persist  for  years. 

Diagnosis  and  Treatment. — The  transition  from  acute  to  chronic 
abscess  and  sinus  is  so  direct  that  these  two  topics — diagnosis  and 
treatment — ^have  been  combined  in  Chapter  II  on  Complication  and 
Sequels  of  Acute  and  Chronic  Urethritis  on  page  103. 

CHRONIC  LYMPHANGEITIS  AND  LYMPHADENITIS. 

Occurrence. — Ljonphangeitis  and  lymphadenitis  are  hardly  ever  seen 
as  chronic  complications  but  they  may  appear  somewhat  regularly 
during  exacerbations  of  chronic  urethritis,  and  thus  constitute  acute 
complications,  but  they  will  need  on  this  account  no  further  discussion 
than  that  already  given  on  page  105. 

CHRONIC  GLANDULAR  COMPLICATIONS  OF  ANTERIOR 
GONOCOCCAL  CHRONIC  URETHRITIS. 

Varieties  and  Importance  are  the  same  as  noted  in  the  Chapter  on 
Acute  Complications  on  page  106,  but  the  essential  featiu-e  is  persistent 
cavity,  sinus  and  fistula  with  many  relapses  within  the  glands  them- 
selves or  during  the  course  of  temporary  return  of  activity  of  the 
urethritis.    Littritis,  folliculitis  and  cowperitis  are  the  chief  forms. 


312    COMPLICATIOXS  AXD  SEQUELS  OF  CHRONIC  URETHRITIS 

CHRONIC  UTTRITIS  AND  FOLUCULITIS. 

Varieties,  Etiology  and  Pathology  (liil'er  in  no  respect  from  those 
aiivady  gi\en  in  the  acute  i'onns  on  pages  106  and  108,  but  add  the 
development  always  of  the  sinus,  abscess  or  fistula  as  the  final  stage. 

Symptoms. — Subjective  and  objective  symptoms,  during  a  ])eriod 
of  acti\ity  or  exacerbation,  reintroduce  those  of  the  initial  acute  com- 
l)lication,  but  during  the  period  of  chronic  quiescence  the  discharge  is 
complained  of  by  the  patient  and  the  examining  finger  detects  multiple 
nodes  which  rei)rescnt  the  afVected  glands  as  they  are  (listril)uted  along 
the  urethra.  The  ])ressure  of  the  finger  or  of  an  ex])loring  instrument 
excites  the  discharge  in  which  gonococci  should  always  be  looked  for 
as  a  matter  of  clinical  and  sociologic  importance. 

Diagnosis  and  Treatment. — Repetition  is  avoided  an<l  the  close  rela- 
tion of  acute  and  chronic  littritis  and  folliculitis  em])hasized  by  dis- 
cussion of  their  diagnosis  antl  treatment  together  in  Chapter  II  on 
Complications  and  Sequels  of  iVcute  Urethritis  on  page  108. 

CHRONIC  COWPERITIS  WITHOUT  AND  WITH  RETENTION. 

Occurrence,  Significance  and  Varieties  are  the  analogues  of  those 
enimierated  under  the  acute  complications  on  page  109,  the  fewer 
the  symptoms  and  the  more  persistent  the  discharge,  the  greater 
the  danger  of  imexpected  infection.  Thus  the  chronic  catarrhal  or 
suppiu-ating  discharge  makes  cowperitis  without  retention  extremely 
important. 

Pathology. — Pathology  is  sufficiently  discussed  on  page  111  and  it 
may  be  summed  up  by  stating  that  the  gland  is  a  chronic  suppurat- 
ing pocket  if  without  retention  or  if  with  retention  an  abscess  which 
frequently  repeats  itself  as  an  acute  process.  Sinuses  and  fistulte  may 
be  complicating  or  resulting  lesions. 

Symptoms. — During  the  period  of  quiescence,  subjective  symptoms 
may  be  practically  absent  except  the  persistent  discharge  of  the  gland 
if  without  retention,  but  during  the  period  of  activit}'  the  patient  suffers 
exactly  as  in  the  acute  complication,  and  if  retention  occurs  precisely 
as  in  a  fresh  abscess.  Thus  there  may  be  an  indolent  discharge,  or  an 
active  one  in  the  former  case,  and  in  the  latter  form  all  the  phenomena 
of  severe  abscess.  The  objective  signs  are  on  perineal  and  rectal 
palpation  a  thick  gland  which  is  more  or  less  incorporated  in  its 
annexa  by  infiltration  and  from  which  pus  may  be  expressed  if  the 
duct  is  patent,  or  an  abscess  if  occluded.  The  probe  will  demon- 
strate sinuses  and  fistuke,  and  the  bacteriologist  the  gonococci  present. 

Diagnosis  and  Treatment. — Botli  forms  of  cowperitis  show  an  inti- 
macy in  all  clinical  features  between  the  acute  and  chronic  forms. 
For  this  reason  the  diagnosis  and  treatment  of  the  chronic  stage  are 
combined  with  those  of  the  acute  period  in  Chapter  II  on  Complica- 
tions and  Sequels  of  Acute  Urethritis  on  page  112. 


CHRONIC  PROSTATITIS  313 

B.  Extragenital  Group. 

Occurrence. — It  is  well  to  repeat  a  point  made  in  the  discussion  of 
acute  complications  of  acute  urethritis.  The  general  characters  of  the 
anterior  urethra  and  its  glands  make  septic  absorption  and  systemic 
complications  rare  and  difficult  but  less  so  the  posterior  aeUte  and 
anteroposterior  acute  lesions.  Systemic  complications  are  most  com- 
mon in  chronic  urethritis  and  in  the  posterior  rather  than  the  anterior 
portion,  under  which  subject  they  are  appropriately  discussed  on  page 
115.  Such  chronic  complications  as  cowperitis,  however,  may  readily 
be  the  sources  of  absorption. 

COMPLICATIONS  OF  POSTERIOR  GONOCOCCAL  CHRONIC 
URETHRITIS. 

Clinical  Features. — The  complications  of  gonococcal  infection  are 
again  adhered  to  as  the  basis  of  comparison  because  they  are  the  most 
pronounced,  extensive  and  typical,  as  to  both  their  symptoms  and 
sequels,  exactly  as  stated  under  acute  complications  on  page  115. 

Varieties.- — Varieties  offer  no  deviation  from  the  classes  and  kinds 
stated  for  the  acute  manifestations,  and  are  a  local  or  urogenital 
group  including  the  sexual,  such  as  prostatitis,  seminal  vesiculitis, 
funiculitis,  epididymitis  and  orchitis,  and  the  urinary,  such  as  urethro- 
cystitis, cystitis,  ureteritis,  pyelitis  and  pyelonephritis.  It  is  again 
to  be  remembered  that  all  these  chronic  complications  of  posterior 
gonococcal  chronic  urethritis  may  at  any  time  renew  themselves  as 
acute  processes  in  all  phases.  The  systemic  or  extraiu-ogenital 
group  embraces  cutaneous,  digestive,  circulatory  (including  abscesses), 
respiratory,  special  sensory  and  locomotory  (including  bony,  articular, 
muscular  and  tenosynovial)  complications,  in  other  words  in  any  and 
every  system  of  the  body. 

A.  Urogenital  Group. 

Varieties.^ — ^Varieties  as  already  stated  include  among  the  sexual 
organs  prostatitis,  seminal  vesiculitis,  funiculitis,  epididjauitis  and 
orchitis,  and  among  the  urinary  organs,  cystitis,  retention  of  urine, 
ureteritis,  pyelitis  and  pyelonephritis.  For  convenience  of  arrange- 
ment the  discussion  of  each  wall  be  in  the  foregoing  anatomical  order. 

1,  Sexual  Forms. 

CHRONIC  PROSTATITIS. 

Varieties,  Etiology  and  Pathology  substantially  reiterate  those  for 
acute  prostatitis.  It  must  be  remembered  that  clu'onic  prostatitis 
may  be  a  superficial  or  deep  folliculitis,  or  a  glandular  parenchjTiiatous 
infection,  with  single  or  multiple  abscesses  and  sometimes  sinuses  and 


314    COMPUCATIOXS  AXD  ."SEQUELS  OF  CHROXIC  URETHRITIS 

fistulie  as  seciiu'ls.  The  jiatholoj^ic  ])n)i,n'ess  cstahlislios  clironic  por- 
sistoiK'o  of  tliis  folliculitis  wliotlKT  t-atarrhal  or  suppurative,  and  of 
the  abscesses  with  rehipses,  retention  and  repetition  of  acute  phe- 
nomena and  theestablislunent  of  eoni])licationsand  secjuels  as  discussed 
under  the  antecedent  acute  subject  on  ])a^e  IIC). 

Symptoms. — Catarrh  or  sup])uration  of  mild  deijree  is  usually  the 
sij:;u  of  superhcial  prostatic  ft)lliculitis,  and  the  {jjreater  the  suppuration 
the  more  marked  the  process.  Relai)se  and  exacerbation  reintroduce 
the  finished  picture  of  the  acute  ])rocess.  The  local  subjecti\e  syni])- 
tonis  are  sensory,  sexual,  vesical  and  rectal  and  somewhat  like  the  acute 
but  nuich  less  distinct  and  definite.  The  sensory  si^ns  are  duller,  the 
vesical  symptoms  occasional  and  chiefly  under  slight  direct  excitants,  the 
sexual  factors  absent  unless  stimulated  by  the  opposite  sex,  and  the  rec- 
tal elements,  chiefly  ])ressure  signs  as  the  feces  rea(  h  the  gland  and  cause 
discharge  of  the  follicidar  contents,  as  nuicus,  pus  and  imhealthy  ])ros- 
tatic  secretion.  Definite  rectal  pain  is  rare,  but  discomfort  is  common. 
The  local  objective  signs  are  as  in  the  acute  condition,  urinary  and 
rectal.  The  urinary  diagno.sis  Avith  the  se\en-glass  test  of  the  author 
du])licates  the  findings  described  in  Chapter  VIII  on  page  455,  in  that  the 
first  three  and  fifth  glasses  contain  the  urethral  and  prostatic  elements, 
and  only  the  fourth  or  catheterized  glass  the  normal  urine  if  the  bladder 
is  healthy.  The  sixth  and  seventh  glasses  also  contain  a  little  prostatic 
detritus.  Laboratory  analysis  establishes  the  presence  of  the  gono- 
cocci  or  other  organisms,  and  the  prostate  as  the  source  of  most  or  all 
the  detritus.  Rectal  examination  displays  in  follicular  prostatitis  the 
gland  enlarged,  soft  as  a  whole,  and  rather  insensitive,  and  secures 
fluid  on  expression  which  is  rich  in  prostatic  epithelium,  pus  and 
unhealthy  secretion.  On  the  other  hand,  in  parenchymatous  prostatitis 
the  gland  is  enlarged  as  a  whole  or  in  lobes,  tense,  soft  or  fluctuating 
in  accordance  with  the  condition  of  the  abscess,  which  may  be  small 
and  numerous  or  large  and  generalized.  The  gland  may  be  reduced  in 
size  at  one  or  more  points  through  the  destruction  of  the  abscess.  The 
expressed  fluid  is  rich  in  pus  and  very  scant  in  prostatic  secretion 
and  proves  extensive  suppuration.  The  bimanual  examination  is 
often  employed  when  the  prostate  cannot  be  suitably  explored  by 
rectal  examination  alone  in  the  standing  and  stooping  position  and 
requires  for  complete  determination  bimanual  investigation.  The 
patient  is  in  the  recumbent  position  with  the  lower  extremities  flexed 
and  widely  separated  and  the  trunk  slightly  flexed  in  order  to  relax 
the  abdominal  muscles.  The  urethra  is  irrigated  when  possible  by 
filling  the  bladder  to  distention  and  allowing  the  i)atient  to  evacuate 
it,  thus  cleansing  both  the  posterior  and  anterior  ])ortions  of  the  canal. 
The  bladder  is  again  flUcd  and  with  the  abdominal  hand  it  is  slowly 
but  surely  depressed  toward  the  perinemn  and  anus,  thus  carrjdng 
downward  the  prostate  which  is  also  explored  by  the  one  or  two 
fingers  of  the  other  hand  well  lubricated  and  passed  into  the  bowel. 
Any  specimen  expressed  during  this  examination  is  collected  in  a  ster- 
ilized glass  of  sterilized  water  and  sent  to  the  laboratory.    Asepsis  of 


Fig.  76. — Secretion  of  normal  prostate,     a,  spermato crystals;  h,  prostatic  bodies; 
c,  lecithin  bodies;  d,  lymphocyte;  e,  pus  cells.     (After  Oberlaender-KoUmann.') 


Fig.  77. — Secretion  of  mild  catarrh  of  the  prostate,     a,  lecithin  bodies;  h  and  c,  lympho- 
cytes and  leukocytes  or  pus  cells.     (After  Oberlaender-Kollmann.) 


Fig.  78. — Secretion  of  severe  catarrh  of  the  prostate,     a,  lecithin  bodies;  h,  epithelium; 
c  and  d,  leukocytes  in  fatty  degeneration.     (After  Oberlaender-Kollmann.) 

1  Oberlaender-Kollmann:    Die  Chronische  Gonorrhoe,  1910. 


316    COMPLICATIOXS  AXD  SEQUELS  OF  CHROXIC  URETHRITIS 

the  specimen  requires  wnshinn;  the  ghuis  and  meatus  also.    If  no  speci- 
men is  desired  the  detail  of  irrigating  the  urethra  may  be  omitted. 

The  systemic  subjective  and  objective  sjoiiptoms  are  less  marked 
than  those  of  the  acute  com])lieati()n,  and  are  summed  up  in  feverish- 
ness  and  malaise.  During  exacerbations,  however,  there  is  not  the 
slightest  distinction  between  the  chronic  an<l  the  acute  exee])t  that 
chronic  cases  have  a  tendency  toward  periprostatitis  and  infiltration. 
Even  partial  urethral  obstruction  through  the  edema  and  the  swelling 
ma\"  be  present. 


Fig.  79. — Massage  of  the  prostate  for  excretion  of  its  secretion.  The  prostatic 
secretion  is  collected  in  a  sterile  glass  which  has  been  half  filled  with  sterilized  water. 
The  penis  should  be  washed  with  mild  antiseptic  and  the  anterior  urethra  irrigated  so 
that  as  far  as  possible  the  specimen  shall  be  that  of  the  prostate.  The  flakes  of  pus  vary 
as  to  their  nature  and  are  described  in  the  Chapter  of  Diagnosis.     (Luys.*) 

In  a  broad  sense  chronic,  follicular  prostatitis  and  parenchymatous 
prostatitis  are  important  and  persistent  conditions,  sociologically, 
clmically  and  surgically,  through  the  embryological  structure,  adult 
physiological  function  and  direct  relation  of  the  gland  with  the  poste- 
rior urethra  which  may  in  itself  be  so  commonly  the  seat  of  gonococcal 
chronic  lesions. 


'  Loc.  cit. 


CHRONIC  PROSTATITIS  317 

Diagnosis  and  Treatment. — Chronic  prostatitis  of  both  th(;  h^lli'uhn- 
and  parenchymatous  forms  is  a  very  vast  subject  and  so  cicjsely 
related  in  all  respects  with  the  acute  manifestations  that  directness  of 
discussion  required  consideration  of  the  diagnosis  and  treatment  of 
chronic  prostatic  lesions  with  acute  forms  in  Chapter  II  on  Compli- 
cations and  Sequels  of  Acute  Urethritis  on  page  119.  On  the  other 
hand,  however,  the  work  of  Young,  Geraghty  and  Stevens^  is  probably 
the  best  study  of  this  subject  whose  chief  conclusions  should  always 
be  remembered. 

These  authors  compared  normal  and  pathological  secretions,  obtain- 
ing specimens  after  rectal  massage,  either  with  free  flow  or  more  or 
less  mixed  with  contents  of  the  bladder.  Precipitation  and  centri- 
fugation  were  employed.  Separation  of  prostatic  and  vesicular  secre- 
tions was  not  done  after  the  method  of  the  author's  seven-glass  test, 
discussed  on  page  455.  Normal  secretion  is  a  combined  fluid,  whitish 
or  yellowish,  thick,  turbid,  opalescent,  homogeneous  and  viscid  from 
the  prostate.  The  vesicles  add  semisolid  strings  and  slugs.  The 
reaction  is  faintly  alkaline  to  litmus,  but  acid  to  phthalein.  Micro- 
scopically in  predominance  are  lecithin,  columnar  epithelium,  granules 
and  corpora  amylacea  and  scattered  numbers  of  spermatozoa,  mucin 
globules,  red  blood  cells  and  white  blood  cells.  The  lecithin  appears 
in  small  or  large  granules,  never  over  the  diameter  of  red  blood  cells. 
The  latter  occur  in  masses  through  disease  or  traumatism  of  the 
examination.  Leukocytes  are  absent  in  normal  secretion.  Finger  and 
Posner"'^  were  early  in  emphasizing  careful  frequent  examinations  com- 
bined with  rectal  palpation.  Goldberg^  states  that  the  secretion  is  con- 
clusive in  doubtful  rectal  examination,  a  fact  repeated  by  Xotthafft.^ 
The  secretion  is  much  more  important  than  the  rectal  conditions,  and 
pathological  elements  such  as  pus  may  not  be  present,  except  after 
from  two  to  five  massages.  Urethral  pus  must  be  excluded  as  indicated 
by  Gassmann.^  Young's  method  of  obtaining  specimens  rests  on  a  full 
bladder,  a  three-glass  evacuation,  thorough  prostatic  massage  and 
collection  of  the  specimen  at  the  meatus.  Another  urination  is 
attempted  or  irrigation  performed  if  the  specimen  does  not  present 
at  the  meatus.  The  product  is  centrifuged.  Pus  in  the  urethra  indi- 
cates irrigation.  Young's  four  steps  should  be  preceded  by  the  author's 
seven-glass  test,  described  on  page  455,  in  order  to  minimize  error, 
and  consist  in  macroscopic,  microscopic,  staining  and  culture  examina- 
tions. The  gross  color  is  yellowish,  reddish,  greenish,  milky  white  or 
clear.  Schlagintweit's  method  of  dripping  the  secretion  into  a  glass  of 
water  is  already  noted  on  page  120.  The  microscopic  findings  show 
leukocytes  and  pus  cells  mixed  with  normal  elements.  The  pus  pre- 
dominates in  inverse  ratio  to  the  normal  elements  and  proportional 
with  the  disease.    Bering"^  says  that  leukocytes  of  prostatitis  are  smaller, 

1  Johns  Hopkins  Hospital  Reports,  xiii,  1906. 

2  Rothschild:  Deut.  med.  Woch.,  1900. 

3  Abstract  in  Monatsbeiichte  f.  Urol.,  1901.  *  Archiv.  f.  Derm.  u.  Syph.,  1904. 
6  Centralb.  f.  d.  Kiank.  d.  Harn.  u.  Sex.  Org,  Bd.  s^^ 

6  Archiv.  f .  Derm.  u.  Syph.,  1905, 


318    COMPLICATIONS  AND  SEQUELS  OF  CHRONIC  URErilRiriS 

jieciiliarly  granular  and  chiefly  mononuclear  in  comparison  with  those 
of  urethritis.  Bonn'  claims  that  small  prostatic  epithelia  guarantee 
the  source  of  the  leukocytes,  and  Bering  claims  that  chronic  prostatitis 
decreases  the  munber  but  increases  the  size  of  corpora  amylacea. 
Fuerbringer,  quoted  by  Young,  reported  re^^val  of  inactive  sperma- 
tozoa ilurhig  favorable  treatment  and  SchlagintAveit  foimd  that  the 
addition  of  prostatic  fluid  to  seminal  \esicular  secretion  secured  such 
revival.  Young  prefers  Wederhake's  method  of  staining  for  the  ordi- 
nary specimen,  and  blood  stains  for  distinction  of  the  leukocytes.  He 
believes  that  the  diagnosis  of  chronic  i)rostatitis  rests  on  rectal  palpa- 
tion and  examhiation  of  the  secretion.  Young  does  not  give  suitable 
weight  to  urethroscopy  in  this  field,  nor  fitting  warning  against  the 
results  of  traumatism  of  the  prostate  by  im])roper  massage.  The 
writer  has  seen  ])rostatic  massage  done  so  violently  that  acute  inflamma- 
tion would  certainly  follow  if  the  parotid  gland  or  the  testicle  or  the 
o^■ary  were  similarly  manipulated.  Misleading  results  must  follow 
such  injudicious  eft'ort.  Yoimg's  conclusions  as  to  bacteriology  may 
be  abbreviated  as  follows:  1 .  The  urethroscope  preceded  and  followed 
by  irrigaticm  and  associated  with  cultures  is  a  valuable  detail;  2. 
shreds  in  the  first  glass  do  not  vitiate  the  bacteriology.  Positive 
residts  are  more  frequent  without  shreds.  3.  Bacteria  are  not  frequent 
in  chronic  prostatitis  under  treatment.  4.  ]Multiple  hifectitm  is  not 
unusual,  and  the  same  patient  may  have  ditt'erent  organisms  at  several 
examinations,  requiring  great  judgment.  5.  Bacteria  may  occur  in 
nongonococcal  cases.'  ().  Frequency  and  persistence  of  gonococci  are 
not  yet  settled.  7.  The  value  of  case  reports  in  literature  depends  on 
the  method  used.  8.  Smears  for  bacteria  are  \'aliiable  only  if  secured 
imder  full  precautions. 

Young's  summary  is  very  important,  and  is  as  follows:  1.  Pus  is 
present  in  practically  all  chronic  prostatitis,  especially  later  than  the 
second  massage.  The  microscope  is  necessary  for  accuracy.  Poly- 
morphonuclear neutrophiles  predominate,  but  Bering  finds  mono- 
nuclears. 2.  The  amoinit  of  pus  bears  direct  relation  to  the  prostatitis, 
but  mild  cases  may  have  much  and  severe  cases  little  pus.  3.  Pus 
decreases  usually  with  treatment,  but  more  marked  progress  may  follow 
rest  from  treatment.  4.  Normal  are  in  inverse  ratio  to  pus  elements, 
but  as  yet  without  definite  diagnostic  or  prognostic  value.  5.  Stain- 
ing is  of  value  for  bacteria  only.  0.  Pus  seems  to  bear  no  direct  rela- 
tion with  the  activity  of  spermatozoa,  but  treatment  revives  them. 
7.  Reaction  to  litmus  is  nearly  alwa\s  alkaline. 

CHRONIC  SEMINAL  VESICULITIS  OR  SPERMATOCYSTITIS. 

Occurrence. — Chronic  involvement  of  the  seminal  vesicles  is  a  much 
more  common  occurrence  than  was  at  one  time  supposed.  ]\Iany 
of  the  older  works  discuss  the  complication  in  a  more  or  less  casual  and 

»  Prager.  med.  Wocb.,  1893. 


CHRONIC  SEMINAL  VESICUUTIS  OR  SPERMATOCYSriTIS     319 

fragmentary  manner.  The  well-recognized  work,  however,  of  luller,' 
and  later  of  Young'^  in  this  country,  has  proved  beytjiid  all  question  its 
frequent  incidence  and  far-r(;aching  possible  results.  It  is  necessarily 
more  common  in  chronic  than  in  acute  urethral  infection. 


CORPUS 
CAVERNOSUM 


COWPER'S' 
GLAND 

BULBO- 

CAVERNOSUS 

MUSCLE 


Fig.  80. — Male  pelvic  organs  seen  from  right  side.  Bladder  and  rectum  distended; 
relations  of  the  peritoneum  to  the  bladder  and  rectum  are  clearly  shown.  The  arrow 
points  to  the  rectovesical  pouch.''     (Corning.) 

Etiology. — ^Etiology  establishes  the  same  exciting  and  predisposing 
causes  as  in  the  acute.  The  most  important  contributing  factor  is 
sexual  excess  in  masturbation  or  coitus,  during  a  posterior  chronic 
urethritis,  especially  of  progressive  and  relapsing  tA^pe.  From  the 
foci  already  precedent  and  active  in  such  a  urethritis  the  gonococci 
extend  by  direct  contiguity  along  the  ejaculatory  ducts,  themselves 
congested  as  the  result  of  such  indiscretions. 

Varieties. — Varieties  contribute  no  addition  to  those  discussed  under 
acute  seminal  vesiculitis,  but  the  important  ones  are  the  fundamental 
types:  spermatocystitis  with  occlusion  and  without  occlusion  of  the 

1  Tr.  Am.  Urol.  Assn.,  iii,  344;  Ibid.,  vi,  274;  Med.  Rec,  Januarj-  23,  1915. 

2  Tr.  Am.  Assn.  Gen.-Urin.  Surg.,  1912,  vii,  73. 

3  Gray's  Anatomy,  Lea  &  Febiger,  Philadelphia,  19 IS. 


320    COMPLICATIOXS  AXD  SEQUELS  OF  ClIROXIC  URETHRITIS 

ducts,  which  really  embrace  all  other  forms.  Tuberculosis  of  the 
seminal  vesicles  is  not  a  part  of  this  work  except  for  dilferentiation. 
Primary  and  secondary  seminal  ^•esiculitis  have  also  been  previously 
discussed,  the  former  as  exemplified  chiefly  by  tuberculous,  and  the 
latter  by  gonococcal  and  allied  pyogenic  infection.  Catarrhal  seminal 
\esieulitis  is  either  the  expression  of  sexual  excess  or  the  terminal  sign 
of  the  gonococcal  form. 


MUSCULA 
TUNI 


VAS 

DEFERENS 


COWPER'S  EXCRETORY 


Fig.  81. — The  urinary  bladder,  distended,  with  surrounding  structures,  viewed  from 
behind.      (Spalteholz.) 

Pathology. — Pathology  must  respect  the  two  forms  of  spermato- 
cystitis,  without  and  with  retention.  After  the  stages  pictured  for  acute 
pathology  on  page  127,  one  finds  in  chronic  seminal  vesiculitis  without 
retention  extensive  and  deep  desquamation  of  epithelium,  purulence, 
small  cell  infiltration,  sclerosis,  patency  of  the  duct  which  imitates 
these  findings  and  discharges  into  the  urethra.  Chronic  spermato- 
cystitls  with  retention  reveals  a  duct  closed  by  infiltration  and  stricture 
of  its  walls  followed  either  by  an  indolent  accumulation  and  later 
evacuation  of  pus,  or  a  temporarily  active  accumulation  and  discharge; 
in  other  words,  subacute  abscess  or  relapsing  acute  phlegmon  with  all 
the  pathogenesis  as  described  on  page  130.  Furthermore,  the  abscess 
may  ha^■e  developed  the  sinuses  and  fistula*  noted  under  the  acute  com- 
plication as  having  perineal,  vesical,  rectal  and  very  rarely  peritoneal 
outlet. 

'  Loc.  cit. 


CHRONIC  SEMINAL  VKHKHJLJTIS  OR  SPERMATOCYST/TfS     321 


Thomas^  gives  Fuller-  ai)(l  Lloyd"*  credit  as  pioneers  in  this  field  and 
quotes  Picker*  as  having  in  191 1  before  the  111  Congress  of  the  German 


AMPULLA     OF 


SEMINAL 
VESICLE 


SEMINAL 
VESICLES 


EJACULATOPV 
DUCT 


VERUMONTANUM 


URETHRA 

Fig.  82. — The  ejaculatory  ducts  viewed  from  in  front  aiid  above.^ 


VAS \ 


PROSTATE 

Fig.  83. — -Prostate  with  seminal  vesicles  and  seminal  ducts  viewed  from  in  front 

and  above. ^ 

1  Tr.  Philadelphia  Acad,  of  Surg.,  x\Ti,  21. 

2  Jour.  Am.  Med.  Assn.,  May  4,  1901,  p.  1228;  New  York  Med.  Rec,  October  30, 
1909;  Jour.  Am.  Med.  Assn.,  November  30,  1912,  p.  1959. 

3  British  Med.  Jour.,  April  20,  1889,  p.  882;  Lancet,  1891,  ii,  975. 
*  XIV  International  Medical  Congress,  London,  1913. 

s  Gray's  Anatomy,  19th  ed.,  1913.  «  Ibid.,  20th  ed.,  1918. 

21 


322    COMPLICATIONS  AND  SEQUELS  OF  CHRONIC  URETHRITIS 

Urologic  Society  presented  a  classic  study  of  about  150  seminal  vesicles 
dissecting  out  the  tube  systems  after  injecting  the  vasa  dcferentia 
with  bisnuith  jxiste,  as  follows:  "From  the  material  ('om]irising  50 
normal  and  10  pathological  specimens,  he  makes  the  following  ana- 
tomical classification:  (1)  simple  straight  tubes;  (2)  thick  twisted  tubes 
with  or  without  diverticula;  (3)  thin  twisted  tubes  with  or  without 
diverticula;  (4)  main  tubes  straight  or  twisted  with  larger  grapelike 
arranged  diverticula;  (5)  short  main  tube  with  large  irregular  ramified 
branches;  (6)  miscellaneous,  comprising  (a)  embryological  abnormali- 
ties and  (b)  pathological  conditions.  Of  the  normal  specimens  about 
one-third  belong  to  tjqpes  (1),  (2)  and  (3)  and  two-thirds  to  (4)  and  (5). 
The  lengths  of  the  various  vesicles  measiu-ed  from  (>  to  23  cm.;  the 
capacities  varied  from  3  to  11 .5  c.c.  Thus  it  is  seen  that  the  seminal 
vesicles  of  the  male  urethra  possess  the  most  extensive  secretory  sur- 
face with  the  worst  drainage." 

Symptoms. — As  in  pathology  the  two  basic  classes  of  case  must  be 
regarded.  Chronic  seminal  vesiculitis  without  retention  is  probabl^^ 
a  much  more  common  condition  than  ordinarily  recognized,  because 
the  drainage  causes  few  subjective  s>^nptoms  and  lea\'es  only  objective 
proof  which  is  not  easy.  The  case  is,  therefore,  casually  diagnosed  as 
one  of  posterior  chronic  lu-ethritis  whereas  this  complication  is  really 
the  prevailing  ^ment.  Its  local  subjective  symptoms  are  sensory, 
urinary,  m-ethral,  rectal  and  sexual,  exactly  as  enumerated  for  acute 
cases  but  they  are  masked,  indefined  and  relatively  indifferent.  The 
sensory  signs  are  discomfort  and  uneasiness  rather  than  pain;  the 
urinary  function  is  little  disturbed  except  in  increased  frequency;  the 
lu'ethral  condition  shows  a  constant  discharge  of  rather  large  mucous 
masses  and  strings;  the  rectal  factors  are  absent  or  very  slight,  excepting 
alone  expression  of  semen  during  defecation,  and  the  sexual  details 
are  undue  stimulation  probably  through  the  inability  of  the  sac  to 
hold  the  semen.  Thus  coitus  increases  the  discharge  and  the  disturb- 
ance and  this  weakness  of  the  sacs  leads  to  very  frequent  nocturnal 
emissions  of  which  the  patients  greatly  complain. 

The  local  objective  s\Tnptoms  recognize  the  anatomy  as  given  in 
previous  pages,  occur  on  one  or  both  sides  equally  or  differently  and 
comprise  chiefly  enlargement  and  prominence,  thickening  and  sclerosis, 
thickening  and  bogginess,  practical  absence  of  tenderness  and  free 
expression  of  the  characteristic  shreds  and  pus.  Urinalysis  after  the 
author's  seven-glass  test,  which  is  described  on  ])age  455,  shows  few 
shreds  in  the  first  two  or  anterior  urethral  glasses,  the  classic  slugs  or 
strings  of  pus  and  mucus  in  the  third  or  posterior  urethral  glass,  normal 
urine  in  the  fourth  or  bladder  glass,  prostatic  elements  in  the  fifth 
glass  and  extraordinary  masses  of  shreds,  slugs,  strings,  nmcus  and  pus 
in  the  sixth  and  seventh  glasses  from  the  two  vesicles.  With  the 
prostate  normal  these  facts  establish  the  diagnosis  but  bacteriological 
and  microscopic  investigation  are  required  for  detection  of  the 
organisms  and  the  distinction  between  prostatic  and  spermatocystic 
products. 


CHRONIC  SEMINAL  VESICULITIS  OR  SPEItMATOCYSTITIS     323 

The  systemic  subjective  and  objective  symptoms  are  the  same  in 
character,  less  in  degree  but  greater  in  absorption  elements  than  seen 
in  a(  ute  cases.  Similar  and  more  frequent  sequels,  especially  arthritis, 
as  the  best  example,  are  (;ommon  experience.  I'o  this  class  belongs 
urinary  and  urethral  chill  excited  by  the  examining  finger  and  should 
never  be  an  unexpected  condition. 

The  symptom-complex  of  chronic  sperm atocystitis  with  retention 
reiterates  all  the  foregoing  indolent  conditions  but  adds  the  presence 
of  abscess  without  or  within  the  cavity  of  the  sac.  Such  abscess  is 
chronic  and  persistent  or  acute  and  subacute  with  relapses.  Examina- 
tion during  an  acute  exacerbation  adds  no  feature  to  those  portrayed 
for  acute  varieties.    Systemic  absorption,  however,  is  in  greater  or  less 


Fig.  84. — Chronic  seminal  pyovesiculosis.  Fifty  minims  of  coUargol  injected  into 
each  side,  great  enlargement,  irregularity  and  tortuosity  are  shown.  (Thomas  and 
Pancoast.') 

degree  almost  universal,  and  the  complications  of  this  condition 
although  itself  a  coniplication  are  the  same  as  those  stated  under  the 
same  subject.  The  same  rule  applied  to  the  stage  of  termination  with 
emphasis  on  the  facts  of  absorption  and  in  many  of  no  recovery  what- 
ever in  the  true  sense  in  that  one  or  both  vesicles  are  permanently 
damaged  or  even  destroyed. 

Significance. — In  summarizing  their  studies,  Thomas  and  Pancoast^ 
give  the  following  conclusions : 

1.  Chronic  seminal  vesiculitis  is  more  prevalent  than  realized  and 
possesses   confusing   and   varied   symptoms   even   remote   from   the 


1  Loc.  cit. 


2  Loc.  cit.,  p.  26. 


oL'4    COMPLICATIOXS  AXD  SEQUELS  OF  CIIROXIC  URETHRITIS 

urinary  tract.     IniVction  is  invariably  inixed,  from  whicli  in  clironic 
forms  the  tionococcus  is  almost  im])ossible  to  isolate. 

2.  The  disease  is  analogous  to  pus  tubes  in  the  female  with  similar 
serious  and  diffieult  ])rol)lems  of  treatment  without  as  yet  full  acknowl- 
edgment by  the  i)rofession. 

3.  Treatment  must  be  selected  according  to  anatomy  and  ])athology 
of  the  particular  vesicles,  ejaculatory  duets  and  vasa  deferentia,  usually 
determined  by  proper  rectal  examination,  massage  and  laboratory 
diagnosis,  su])i)lcmcnte(l  by  \aso])uncture  and  coll-argol  radiogra])hy. 

4.  Experienced  ])ersistcnt  massage  will  cure  most  i)atients  in  time. 
When  ineffectual,  vasopuncture  and  vasostomy  afford  direct  medication; 
but  when  these  fail,  vesiculotomy  or  even  vesiculectomy  alone  avails. 

5.  Bilateral  vasopuncture  and  collargol  medication  have  resulted  in 
at  least  tem])orary  cure  of  persistent  cases. 

6.  "Collargol  radiograms  in  a  series  of  normal  and  pathological 
cases  have  demonstrated,  (a)  by  comparison  i?i  vivo  and  in  vitro,  graphic 
portrayal  of  an  ejaculatory  duct  sphincter;  (b)  the  intimate  relation- 
shi])  between  the  ureter  and  the  seminal  vesicle,  whereby  urethral 
irritation  and  lu'inary  obstruction  may  occur  in  the  event  of  an  enlarged 
and  iuHamed  A'esicle ;  (c)  the  presence  of  stricture  or  obstruction  of  the 
vas;  {d)  congenital  anomalies  of  the  vesicuhie  seminales;  (e)  inflamma- 
tory enlargements,  especially  loculated  collections  of  pus  or  seminal 
pyovesiculosis." 

Diagnosis  and  Treatment. — For  the  sake  of  impressing  the  direct 
transition  from  the  acute  to  the  chronic  forms  and  their  otherwise 
close  relation,  consideration  of  chronic  invohTment  as  to  diagnosis  and 
treatment  is  embodied  with  that  of  the  acute  stages  in  Chapter  II  on 
Complications  and  Sequels  of  Acute  Urethritis  on  pages  131-4. 

EPIDIDYMITIS,  ORCHITIS  AND  FUNICULITIS. 

Occurrence. — Like  the  acute  forms  this  series  of  com])lications,  most 
intimately  related  to  each  other,  is  one  of  the  most  common  chrojiic 
complications  of  chronic  urethritis.  This  fact  gains,  perhaps,  too  little 
respect  for  the  infiltrations,  nodules,  strictures  and  occlusions  of  the 
vas  and  epididymis  which  may  be  life-long. 

Varieties. — The  gonococcal  is  again  the  chief  form  as  to  cause,  Avhile 
the  classes  as  to  occurrence,  location  and  association  remain  the  same 
as  in  the  acute,  which  the  chronic  merely  supersedes.  Nongonococcal 
chronic  epididymitis  probably  does  not  occur  but  complex  infections 
with  the  gonococcus  as  the  most  ])otent  invader  are,  of  course,  frequent. 
Tuberculous  epididymitis  does  not  concern  these  pages. 

Etiology. — Etiology  is  a  perspective  of  the  acute  lesions  and  brings 
out  as  the  systemic  predisposer  low  resistance  to  disease  in  general. 
The  local  inviting  factors  are,  of  course,  posterior  chronic  urethritis 
with  complications  in  the  prostate  and  seminal  vesicles — all  being 
involved  by  direct  continuity  of  mucosa  and  by  intimate  physiological 
function.    Acute  epididvnnitis  is  always  the  antecedent. 


EPIDIDYMITIS,  ORCffTTIS  AND  FUNIC'UIJTIS 


325 


Local  excitiTig  factors  are  excjiiplified  fully  in  Chapter  II  on  page 
147,  but  should  emphasize  trauma  and  sexual  excess  as  the  means  of 
lowering  resistance. 

„-9 


Fig.  85.— Sagittal  section  of  the  left  testicle.  External  segment  of  the  specimen 
1,  acinus;  ^,  albuginea;  S,  corpus  of  Highmore;  4.  interlobular  septula  extending  from 
the  corpus  of  Highmore  to  the  albuginea;  5,  head  of  the  epididymis;  6,  tail  of  the  epidid- 
ymis; 7,  body  of  the  epididymis  not  divided  by  the  section;  8  and  5','visceral  and  parietal 
layer  of  the  vaginalis;  8",  fold  of  the  two  layers;  9,  ca\-ity  of  the  vaginalis;  10,  subepi- 
didymal  cul-de-sac;  11,  spermatic  artery;  12,  veins  of  the  cord;  13,  vas  deferens  in  dotted 
lines  because  it  is  internal  to  the  line  of  section;  14,  hydatid  of  Morgagni-  15  scrotal 
ligament  of  the  testicle.     (Testut.') 


Fig.  86. — Transverse  section  of  the  epididymis.  1,  transverse  section  of  seminiferous 
tubules;  3,  cylindrical  epitheUum  vtith  vibratile  cilia;  5,  transverse  section  of  bloodvessels; 
4,  longitudinal  section  of  bloodvessels;  5,  connective-tissue  bed  between  the  seminiferous 
tubules.     (Schenk.2) 


1  Traite  d'Anatomie  Humaine,  6th  ed.,  No    4 
"Ibid,  (after  Schenk). 


326    COMPLICATIOXS  AND  SEQUELS  OF  CHRONIC  URETHRITIS 

Pathology. — Pathology  was  in  the  acute  lesion  shown  in  essence  to 
be  exfoliation  as  the  leadini::  and  infiltration  as  the  subordinate  factor, 
but  in  the  chronic,  this  relation  is  reversed.  There  may  be  exudate 
coniprisinj^  chieHy  unhealthy  infectious  semen  mixed  with  detritus 
and  comprising  the  temporary  lesion,  but  the  infiltration,  nodulation, 
strictm*e  and  occlusion  of  the  vas  and  ejDidid^niis  at  any  or  many 
points  com})lete  the  ])ermanent  lesions.  These  are  found  chiefly  in 
the  globus  minor  where  the  ducts  have  been  gathered  into  a  single 
tube,  next  in  the  hnmediately  contiguous  vas  and  finally  in  the  globus 
major  of  which  part  may  escape  through  multii)le  tubules.  The 
associated  lesion  of  hydrocele  is  usually  absent  unless  an  exacerbation 
is  present  which  will  duplicate  all  the  other  pathology  of  an  acute 
lesion. 


Fig.  87. — Transverse  section  of  epididynuil  canal.  The  wall  of  the  canal  is  made  up 
of  a  thick  layer  of  smooth  muscle  fibers,  -vs-itlun  which  is  a  layer  of  columnar  epithelium 
cells  with  extraordinarily  long  vibratile  cilia  projecting  into  the  lumen  of  the  canal. 
(Klein.') 

Symptoms. — Symptoms  represent  the  terminal  stage  of  the  acute 
lesion  but  are  indifferent,  not  active  manifestations,  showing  two 
types,  indolent  persistent  and  progressive  relapsing.  The  local  subjec- 
tive sjTiiptoms  decrease  so  that  discomfort  replaces  pain,  except  of 
neuralgic  and  spasmodic  type,  due  perhaps  to  progress  of  exudate  and 
secretion  through  a  strictured  point.  Tenderness  is  less,  and  weight 
moderate  or  even  marked  and  heat  is  absent.  The  local  objective 
sjTiiptoms  likewise  diminish;  tenderness  and  likewise  enlargement  are 
much  less  except  at  the  nodes.  Heat,  edema  and  hydrocele  do  not 
occur  in  the  quiescent  form  but  may  light  up  during  a  relapse.  Dis- 
charge is  not  affected  as  in  the  acute  lesion  unless  an  exacerbation  is 
under  way;  in  other  words,  the  chronic  epididymitis  permits  the  pos- 
terior chronic  urethritis  to  manifest  its  own  symptoms.  The  systemic 
subjective  and  objective  symptoms  are  of  little  moment  except  the 
neuroses,  which  may  be  troublesome  to  patient  and  practitioner. 
When  the  other  systemic  signs  are  prominent  they  are  rather  due  to 
such  associates  as  chronic  seminal  vesiculitis  and  prostatitis.  The 
reverse  rule,  however,  is  followed  during  a  relapse,  which  is  really 
another  acute  attack. 


'  Trait6  d'Anatomie  Humaine,  6th  ed.,  No.  4,  (after  Klein). 


CHRONIC  URETHROCYSTITIS  327 

In  terminating,  complete  resolution  is  often  seen  even  after  prolonged 
attacks,  but  more  frequently  infiltrations,  nodulation,  strictures  and 
contractures  in  moderate  or  severe  degree  and  in  single  or  multiple 
occurrence  are  the  outcome.  The  clinical  importance  and  the  physio- 
logical damage  of  chronic  epididymitis  are  sharply  foreshadowed  in 
the  remarks  under  acute  forms  and  need  no  repetition. 

Diagnosis  and  Treatment. — Of  these  two  headings  of  the  subject  of 
chronic  testicular  involvement  are  combined  with  those  of  correspond- 
ing acute  lesions,  for  the  sake  of  brevity,  in  Chapter  II  on  Complica- 
tions and  Sequels  of  Acute  Urethritis  on  pages  153-7. 

2.    Urinary  Forms. 

General  Considerations. — After  a  posterior  acute  urethritis  has  passed 
into  the  chronic  stage,  particularly  with  complications  and  exacerba- 
tions, it  may  pass  the  sphincter  and  reach  the  urinary  organs  of  itself 
or  through  incidental  causes  and  thus  provoke  one  of  the  following 
complications:  urethrocystitis,  cystitis,  ureteritis,  pyelitis  and  pyelo- 
nephritis, which  may  extend  from  one  to  the  other  region  in  a  most 
active  and  complex  process. 

Etiology. — The  predisposing  and  exciting  factors  have  already  been 
duly  narrated  on  pages  163  and  166.  Emphasis  should  rest,  however, 
on  the  basis  of  proximal  extension  of  the  disease — exacerbations  which 
seem  to  occur  in  subjects  with  catarrhal  diathesis  and  low-grade  resist- 
ance. The  frequency  of  instrumentation  of  the  urethra  and  bladder 
in  chronic  urethritis  makes  direct  infection  common  and  important. 
The  gonococcus  is  the  most  frequent  and  typical  organism. 

CHRONIC  URETHROCYSTITIS. 

Definition  and  Varieties  need  not  be  discussed  further  than  they 
have  been  on  page  163.   The  distribution  of  the  lesions  is  also  the  same. 

Symptoms. — SjTQiptoms  are  characterized  by  the  subsidence  of  the 
acute  suffering  and  persistence  of  the  vesical  damage  so  that  the  organ 
functionates  imperfectly.  The  local  subjective  sjinptoms  are  almost 
solely  frequency  of  urination  and  terminal  pus,  whereas  tenesmus, 
pain,  blood  and  retention  are  almost  absent  or  very  greatly  decreased. 
An  exacerbation  may  light  up  all  the  symptoms  of  a  fresh  acute  attack. 
The  local  objective  symptoms  are  best  shown  by  the  five-glass  test. 
The  anterior  and  control  urethral  glasses  depend  on  the  condition  of 
the  anterior  urethra  which  if  comparatively  normal  will  give  rather 
clean  specimens.  The  posterior  lu-ethral  glass  will  be  turbid.  The 
bladder  or  catheterized  specimen  will  be  turbid,  especially  at  the  last 
few  drops  and  the  massage  specimen  secured  with  a  bladder  distended 
with  boric  acid  water  will  usually  give  the  products  of  a  complicated 
posterior  urethritis. 

The  termination  is  full  recovery  in  a  few  mild  cases  without  damage 
to  the  floor  of  the  bladder.  Restitution  occurs  m  most  cases  leaving 
a  bladder  somewhat  defective  and  a  third  group  show  no  recovery  in 


328    COMPLICATIOXS  A\D  SEQUELS  OF  CHROXIC  URETHRITIS 

the  strict  sense,  in  that  t-lironic,  local  or  jjeneral  cystitis  witli  tendency 
to  weakness  and  irritability,  and  even  exacerbations  of  acnte  inllani- 
niation  continue  through  life.  Slow  extension  from  such  a  bladder 
to  infection  of  the  ureters  and  kidneys  nnist  not  be  fortjotten,  as  the 
true  final  statje. 

Diagnosis  and  Treatment. — In  the  diagnosis,  in  addition  to  the  stand- 
artls  of  carrful  history,  ])hysical  examination,  laboratory  and  blood 
tests  and  trt>atmeiit,  decision  rests  finnly  on  a  careful  urethrocystoscopy. 
The  ditfercntial  points  elicited  by  this  in\estigation  are  given  in  Chapter 
II  on  this  subject  and  should  therefore  not  be  repeated  here. 

As  to  the  treatment  of  the  chronic  lesion,  little  may  be  added  to  "the 
enumeration  and  discussion  of  the  jjrinciples  and  means  laid  down  in 
Chapter  II  on  Complications  and  Sequels  of  Acute  Urethritis  on  page 
1G(),  in  which  are  combined  the  diagnosis  and  treatment  of  both  acute 
and  chronic  forms. 

CHRONIC  CYSTITIS. 

Definition,  Varieties  and  Etiology  offer  no  comments  other  than  those 
given  for  the  acute  lesion  on  page  1G6. 

Pathology. — Pathology  in  essence,  involvement,  microscopy  and  tem- 
porary lesions  stands  unchanged  from  the  description  under  acute 
cystitis  on  page  1()7.  The  permanent  lesions,  however,  are  in  the 
chronic  disease  all  unportant  and  comprise  hypertrophy,  trabecula- 
tions,  sacculations,  deformity  and  chronic  inflammation— localized, 
disseminated  or  general.  The  hApertrophy  is  due  to  the  incessant 
strain  and  spasm  of  the  muscle  and  may  pass  into  well-established 
atrophy.  Trabeculations  arise  from  undue  development  of  various 
muscle  bands  which  resist  the  atrophic  process,  which  goes  on,  however, 
between  them,  thus  leading  to  sacculations  whose  weakening  and 
dilatation  may  even  reach  the  limit  of  hernia  of  the  bladder  wall. 
Deformity  and  contracture  follow  when  atony  does  not  take  place. 
Chronic  inflammation  is  exemplified  by  universal  purulence  and  exfolia- 
tion or  the  same  processes  in  few  or  many  foci.  The  complicating 
lesions  of  ascent  into  the  renal  zone  are  much  more  common  than  in 
acute  cystitis.  * 

Symptoms. — Symptoms  are  barren  if  the  acute  subjecti\e  signs  are 
as  given  unless  a  fresh  outbreak  is  present.  General  depreciation  and 
septic  absorption  may,  however,  attract  attention  and  suggest  the 
added  factors  of  renal  involvement.  The  carduial  local  subjective 
sjTiiptoms  of  pollakimia,  tenesmus,  dysuria,  pain  and  blood  are  all 
decreased  and  some  may  be  absent.  Painful  frequency'  varies  with 
bodily  weariness  and  errors  in  diet  and  the  amount  of  pus  decomposing 
on  the  floor  of  the  bladder.  Tenesmus  is  moderate  if  the  bladder  really 
empties  itself,  but  residuiun  in  cases  with  prostatic  h\']:)ertrophy, 
sacculations  and  atony  may  excite  it  severely.  The  cardinal  local 
objective  symptoms  are  likewise  altered.  Tenderness  is  absent  and 
the  bladder  may  be  palpated  and  percussed  in  its  thickened  enlarged 
state  above  the  symphysis  or  be  beyond  reach  in  its  contractured  form 


CHRONIC  URETERITfS,  PYELITIS  AND  PYELONEPHRITIS     329 

below  it.  Pyuria  is  always  marked  and  (characteristic,  and  hematuria 
occasional  except  in  ulcerating  cases.  The  five-glass  test  should  always 
be  performed  and  gives  characteristic  revelations;  the  massage  glass, 
however,  can  be  successfully  secured  only  after  irrigating  the  bladder 
thoroughly  and  distending  it  with  boric  water.  (Cystoscopy  is  the 
final  and  absolute  objective  analysis  of  the  case  and  is  fully  described 
in  Chapter  XIII  on  page  761.  The  termination  is  as  briefly  outlined 
under  the  subject  of  urethrocystitis  but  apt  to  be  more  severe  and 
prolonged  because  of  the  universal  involvement  of  the  viscus  anrl  for 
the  same  reason  extension  to  the  kidney  is  much  more  common,  and 
therefore  the  complications  of  chronic  cystitis,  itself  a  complication, 
are  ascent  of  the  infection  causing  ureteritis,  pyelitis  and  pyelonephritis. 

Diagnosis. — The  history  affords  an  acute  attack  with  all  the  salient 
subjective  and  objective  systemic  symptoms  declining  or  absent.  The 
laboratory  reports  abundant  sediment  in  the  urine  of  vesical  origin, 
as  proved  by  the  catheter,  which  eliminates  the  lu-ethra,  prostate  and 
seminal  vesicles  as  sources.  The  five-glass  test  shows  purulence  of  the 
bladder  in  the  fourth  or  bladder  glass.  The  distinction  between  tur- 
bidities due  to  pus,  carbonates  and  phosphates  is  tabulated  according 
to  Ultzmann  under  acute  cystitis  on  page  170.  Final  diagnosis,  how- 
ever, of  chronic  cystitis  rests  on  the  use  of  the  cystoscope.  The  reader 
is  referred  to  the  Chapter  on  Cystoscopy  for  determination  of  the 
various  varieties — nonsuppurative  and  suppurative,  membranous, 
ulcerative  and  necrotic,  neoplastic,  calcareous,  tuberculous,  colon 
bacilliary  and  finally  regional,  disseminate  and  general. 

Modern  diagnosis  exemplified  in  cystoscopy,  ureteral  catheterization, 
functional  renal  tests  and  the  like  renders  the  incidence  of  these  com- 
plications in  chronic  form  much  less  frequent,  as  operative  treatment 
intervenes  as  soon  as  it  is  obvious  that  the  affected  kidney  is  definitely 
involved  or  of  no  value. 

Treatment. — Chronic  cystitis  is  a  vast  subject  and  all  the  relations 
and  variations  of  treatment  cannot  be  discussed  fully  except  in  a 
monograph  on  the  subject  itself.  The  principles  and  the  means  of 
treating  it  are  the  same  as  those  of  acute  cystitis.  For  exemplification 
of  the  intimacy  between  acute  and  chronic  cj^stitis,  therefore,  the 
diagnosis  and  treatment  of  each  are  combined  in  Chapter  III  on 
Complications  and  Sequels  of  Acute  Urethritis. 

CHRONIC  URETERITIS,  PYELITIS  AND  PYELONEPHRITIS. 

Occurrence. — These  lesions  in  then  chronic  forms  usually  appear 
more  or  less  in  association  and  very  rarely  individually  as  in  the  acute 
stages.  Thus  they  commonly  form  one  clinical  featm'e  in  which, 
however,  the  kidney  element  may  be  least  in  some  but  most  important 
in  the  average  case. 

Definition  and  Varieties  are  clearly  stated  in  the  description  of  the 
acute  lesions,  on  page  177,  which  may  be  regarded  as  always  pre- 
cursory of  the  chronic. 


330    COMPLICATIOXS  AXD  SEQUELS  OF  CHliOXlC  URETHRITIS 

Etiology. — Etiology  adds  nothing  to  the  portrayal  of  acute  causes, 
but  tlu'  l)loodstreani  and  lyniphchannels  become  more  hnportant 
avenues  of  invasion  than  in  the  former  group,  as  it  is  likely  that 
mixed  infection,  which  is  so  common,  especially  with  the  Bacillus  coli 
conununis,  does  not  occur  excepting  through  one  of  these  routes. 

Symptoms. — Sym])tonis  dis])hi>'  the  ])icture  of  acute  forms  in  a  frame 
of  low-grade  condition.  \Vith()Ut  ])ycloncphritis  chronic  m'cteritis  and 
pyelitis  as  persistent  individual  lesions  probably  do  not  occur  except 
in  relapsing  form  which  is  then  really  a  series  of  frequent  acute  and 
subacute  attacks.  Chronic  jn-elonephritis  ensues  after  the  subsidence 
of  an  acute  attack,  whose  symjotoms  continue  in  masked  or  marked 
intermittent  form  with  low-grade  se])tic  state,  anemia  and  emaciation, 
not  unlike  tuberculosis  in  general  effect.  The  types  of  acute  are  not 
changed  and  include  ascending  and  descending  infection  either  with 
or  without  occlusion  of  the  lu'cter.  The  local  subjective  symptoms 
without  occlusion  are  mild  with  relapses  because  the  i)urulence  drains 
steadily  into  the  bladder,  but  with  occlusion  the  symptoms  are  more 
pronounced  or  even  severe.  Pain,  oliguria  and  anuria  occur.  The  pain 
is  dull  and  dragging  on  one  or  both  sides.  Oliguria  appears  only  during 
exacerbations  if  the  normal  kidney  is  performing  full  function,  and 
anuria  is  usually  absent  unless  a  fresh  extension  or  in^•olvement  of  the 
normal  kidney  supervenes.  The  local  and  systemic  objective  signs  are 
the  persistence  of  feverishness,  infection,  sickness  and  prostration. 
Palpation  freqaiently  reveals  a  tyjiical  mass  in  the  renal  zone  posteriorly 
and  anteriorly  and  may  be  followed  by  sudden  increase  in  pus  in  the 
bladder  in  cases  without  occlusion  and  by  considerable  disturbance  in 
cases  with  occlusion.  Urinalysis  reports  usually  alkaline  urine  from 
mixed  infection  and  decomposition  in  cases  whose  ureters  are  patent 
but,  if  occluded,  the  urine  contains  the  elements  of  the  antecedent 
cystitis  and  perhaps  lu-eteritis.  Normal  urine  may  even  occur  if  the 
bladder  has  recovered  or  a  good  kidney  may  excrete  at  times  the  urine 
of  acute  congestion  scanty,  high  specific  gi*avity,  deficient  urea, 
numerous  various  casts  and  albumin,  for  a  few  hours  or  days.  Sepa- 
rated specuuens  by  m'eteral  catheterization  should  always  be  secured 
and  examined  and  in  draining  cases  will  show  pus  and  mucus  in  slugs 
and  flakes,  blood  cells,  kidney  elements,  bacteria  especially  after 
palpation  and  in  occluded  cases  will  show  no  urine  or  a  few  long  strings 
of  mucus.  Ureteral  catheterization  in  patent  ureters  secures  a  specimen 
from  the  diseased  side  whose  analysis  is  that  just  stated  and  from  the 
normal  side  either  healthy  urine  or  that  of  temporary  renal  congestion. 
Impervious  ureters  accept  catheters  for  only  a  few  centimeters,  which 
bring  away  strings  of  mucus  and  pus  on  withdrawal.  Renal  efficiency 
tests  are  paramoimt  and  gi\e  from  the  healthy  side  at  times  extra- 
ordinarily high  readings  showing  a  perfectly  acting  organ  and  from  the 
diseased  side  either  no  result  at  all  or  a  much  decreased  and  delayed 
output  or  even  a  temporarily  high  efficiency.  In  this  connection 
computation  of  the  total  urea  output  of  both  kidneys  during  the  same 
periods  of  test  and  other  elements  of  urinalysis  will  interpret  any 
seemingly  anomalous  results. 


CHRONIC  RETENTION  OF  URI^  331  . 

The  termination  is  regularly  toward  destruction  of  the  kidney  in 
part  or  in  whole,  through  true  multiple  abscesses  or  a  single  generalized 
phlegmon.  Foci  near  the  surface  of  the  kidney  frequently  rupture  into 
the  perirenal  fat  and  then  induce  extensive  lumbar  abscesses,  or  without 
this  result  bind  the  kidney  with  dense  adhesions.  Unless  the  kidney 
is  removed  there  is  a  slow  absorptive  sepsis,  depreciation  of  health  and 
finally  breakdown  of  the  opposite  kidney.  Very  rarely,  however,  Nature 
brings  the  process  to  an  end  on  the  affected  side  by  walling  it  off  in  a 
more  or  less  cystic  condition.  Death  occurs  either  from  the  slow  sepsis 
or  bilateral  nephritis. 

Diagnosis. — Chronic  ureteropyelorenal  lesions  are  direct  transition 
from  the  corresponding  acute  forms.  All  the  elements  of  diagnosis 
discussed  under  the  latter  subject  apply  to  the  chronic  lesions  and  in 
particular  is  the  employment  of  cystoscopy  necessary  with  its  adju- 
vants of  urinary  separation  by  ureteral  catheterization,  functional  test, 
refined  urinalysis  and  x-ray.- 

•  Treatment. — Chronic  lesions  of  the  kidney,  its  pelvis  and  ureter  do 
not  lend  themselves  to  successful  medicinal  treatment,  although  relapses 
and  recrudescences  may  be  controlled  by  this  means.  Surgical  measures 
are  apt  to  be  first  choice  in  marked  cases.  All  the  principles  of  treat- 
ment apply  to  the  chronic  kidney  disease  laid  down  for  the  acute  form 
in  Chapter  II  on  Complications  and  Sequels  of  Acute  Urethritis  on 
page  188. 

CHRONIC  RETENTION  OF  URINE. 

Definition  and  Occurrence. — Chronic  complete  retention  of  urine 
cannot  occur  w^ithout  death  of  the  patient,  but  chronic  partial  retention 
with  exacerbations  of  acute  or  subacute  retention  is  very  common. 
It  may  be  denominated  relapsing  retention  as  indicated  under  the  acute 
lesion,  and  is  seen  most  frequently  in  the  obstruction  due  to  stricture 
of  the  urethra  wdth  its  great  difficulty  of  urination  and  in  that  due  to 
enlargement  of  the  prostate  with  its  residual  urine. 

Etiology  denominates  this  as  a  very  common  sequel  of  gonococcal 
chronic  urethritis  in  association  with  stricture  and  prostatic  involve- 
ment. Mild  excitants  produce  the  relapses  of  total  obstruction.  The 
other  causal  factors  are  narrated  under  the  description  of  acute 
retention  on  page  197. 

Symptoms. — Symptoms  in  addition  to  those  described  for  stricture 
of  the  urethra  on  page  343  and  prostatic  hypertrophy  on  page  943, 
comprise  the  details  already  given  for  the  acute  manifestations. 

Diagnosis  and  Treatment. — Nothing  can  be  added  to  the  general 
subject  of  diagnosis  and  treatment  as  given  in  Chapter  II  on  Compli- 
cations and  Sequels  of  Acute  Urethritis  on  page  198. 

Cure. — In  the  matter  of  persistence  of  the  gonococci  in  the  prostate 
in  its  personal  and  social  prophylactic  relations  one  of  the  best  studies 
is  that  by  Saxe,^  who  draws  the  following  conclusions: 

1  Tr.  Am.  Urol.  Assn.,  1909,  iii,  131. 


332    COMPLICATIOXS  AXD  SEQUELS  OF  CHROXIC  URETHRITIS 

"  1.  Thoroiiirh  irriuation  of  the  urethra  before  massasjinc;  the  prostate 
is  essential  in  order  to  exehide  eontamlnation  of  the  prostatic  secretion 
by  pus  and  bacteria  from  tlie  urethra. 

2.  Injections  of  fifteen  drops  of  a  1  i)cr  cent,  sohition  of  silver  nitrate 
into  the  urethra  twenty-four  to  forty-eijjjht  hoiu-s  before  prostatic  mas- 
sage sometimes  reveal  ji'onoeocci,  when  other  means  have  failed. 

3.  A  double  stain  of  eosin  and  methylene  blue  in  ])ure  methyl  alcohol, 
after  the  maimer  of  the  well-known  blood-stains,  is  excellent  in  the 
morpholoj^ical  study  of  prostatic  smears.  Gram's  stain  is  essential, 
but  is  misleading  unless  properly  ajjplied. 

4.  Cultm-es,  while  desirable,  are  often  unsuccessful,  owing  to  the 
capricious  character  of  the  gonococcus.  Negative  cultures  are  not 
conclusive. 

5.  Of  ISO  cases  of  chronic  gonorrheal  infection  (50  ])er  cent,  showed 
prostatitis.    The  older  the  infection,  the  more  frequent  the  prostatitis. 

0.  Of  the  lOS  cases  of  prostatitis  studied,  31,  or  28. 7  i)er  cent., 
showed  gonoeocci  in  the  prostatic  secretion.  The  older  the  infection 
the  less  probable  is  the  finding  of  gonoeocci  in  the  prostate.  After 
three  years,  gonoeocci  are  found  rarely,  even  after  most  persistent 
efforts.  ]\Iany  and  thorough  examinations  are  needed  before  we  can 
be  at  all  certain  that  the  gonococcus  is  absent  from  the  prostate. 

7.  ]\lixed  infection  occurred  in  S()  per  cent,  of  the  cases  studied. 
The  gonococcus  alone  occurred  in  only  5  cases  out  of  108,  and  all  5  were 
cases  of  less  than  one  year's  duration.  The  older  the  case  the  more 
prevalent  was  the  mixed  infection.  Sta])hylococci  occurred  in  74  j)er 
cent.;  bacilli  in  28  per  cent.;  Gram-positive  diplococci  in  10  per  cent., 
and  streptococci  in  7.6  per  cent,  of  cases  with  mixed  infection. 

9.  The  absolute  need  of  microscopic  examinations  of  prostatic 
secretion  was  shown  by  the  fact  that  palpatory  signs  were  absent  in 
38  cases  (35  per  cent.),  while  13  cases  (12  per  cent.),  showed  absolutely 
clear  urine,  although  the  smears  showed  prostatic  infection. 

10.  Gonorrheal  prostatitis  is  ciu-able  by  proper  treatment  in  the 
great  majority  of  cases. 

11.  Consent  to  marriage  should  not  be  given  until  all  methods  of 
examination  have  been  exhausted  and  until  the  possibility  of  a  post- 
marital  infection  is  practically  excluded,  in  the  present  state  of  our 
knowledge." 

A  similar  research  was  made  by  Wolbarst^  with  much  the  same 
conclusions. 

B.  Systemic  oh  Extraurogenital  Group. 

Occurrence. — In  either  acute  or  chronic  gonococcal  lu-etlu-al  infections 
constitutional  comjilications  may  occur,  perhaps  the  more  frequently 
in  the  chronic  lesions  on  account  of  the  absori)tion  and  the  exacerba- 
tions, which  may  dui)licate  acute  attacks.  All  these  extraurogenital 
involvements  have  been  discussed  under  acute  complications  for  the 

1  Tr.  Am.  Urol.  Assn.,  1909,  iii,  155. 


CHRONIC  RETENTION  OF  URINE  333 

reason  that  when  they  then  oe(;ur  they  are  so  proniincnt.  For  this 
reason  no  further  details  will  be  given  here. 

Varieties, — Varieties  in  no  wise  differ  from  those  given  in  the  preced- 
ing chapter,  but  the  most  im])ortant  to  remember  during  chronic 
urethritis  are  the  circulatory  and  the  locomotory,  especially  as  they 
affect  the  heart  and  the  synovial  membranes.  '^I'he  chief  precursors 
of  these  two  classes  of  cases  are  chronic  seminal  vesiculitis  and  chronic 
prostatitis. 

The  reader  is,  therefore,  referred  to  Chapter  III  on  Tomplica- 
tions  and  Sequels  of  Acute  I'rethritis  dealing  solely  with  extragenital 
or  systemic  complications  as  they  appear  in  each  system  of  the 
body-organs. 


CHArTEK    VI. 

COMrLiCATIONS  AND  SEQUELS  OF  CHRONIC 
UKKTIIiaTIS  (CoNTixuED). 

STRICTURE  OF  THE  URETHRA. 

Definition. — "A  stricture  may  be  defined  as  an  obstruction  or  closure, 
partial  or  absolute,  of  the  limien  of  any  passage  in  the  body.  Thus  as 
familiar  cxam])les,  the  term  stricture  is  a])i)lied  to  obstructions  of  the 
nose,  throat,  intestines  and  the  urinary  passages."' 

Varieties. — Varieties  include  (1)  as  to  cause  congenital  and  acquired, 
inflannnatory  and  traimiatic;  (2)  as  to  site,  anterior  and  posterior, 
intra  urethral,  extraurethral;  (3)  as  to  number,  single  and  multiple; 
(4)  as  to  limits,  localized  and  extensive  and  even  general;  (5)  as  to  form, 
linear,  annular,  diaphragmatic,  ^•alvula^  and  bandlike;  (6)  as  to 
behavior,  elastic,  irritable,  inflammatory  and  lapsing;  (7)  as  to  density, 
callous  or  hard,  and  soft  or  contractile;  (8)  as  to  caliber,  "open"  being 
No.  20  French  and  larger,  "  close"  being  No.  20  to  9  French,  both  inclu- 
sive, and  "tight,"  obstructing,  or  "filiform"  strictures  of  9  French  and 
smaller.-  It  is  to  be  noticed  that  an  open  stricture  of  full  caliber  is 
really  an  anatomical  narrowing  of  the  canal  provided  it  is  without  other 
symptoms  of  stricture  as  subsequently  noted;  (9)  as  to  lumen,  centric 
and  eccentric,  direct  and  tortuous;  (10)  as  to  bacteriology,  infectious 
and  suppmative,  noninfectious  and  catarrhal;  (11)  as  to  pathological 
conditions,  organic,  fibrous  and  permanent,  inorganic,  spasmodic  and 
temporary  and  complicated  and  uncomplicated. 

Etiology. — In  children  strictures  are  either  traumatic  or  inflam- 
matory, of  gonococcal  or  nongonococcal  origin.  Inasmuch  as  trauma- 
tism sufficiently  severe  for  the  production  of  stricture  causes  inflam- 
mation it  may  be  said  the  even  tramnatic  strictures  are  inflammatory. 
In  adults  and  in  children,  therefore,  etiology  is  more  or  less  similar. 

The  predisposing  systemic  factors  are  the  <liathesis  already  discussed 
under  etiology  of  acute  and  chronic  urethritis  on  pages  28  and  302, 
pi'oducing  a  catarrhal  tendency  and  continuous  or  relapsing  conditions. 
There  are  no  exciting  systemic  causes. 

The  predisposing  local  causes  are  delicacy  of  the  mucous  membrane 
and  its  rather  poor  recuperative  powers,  tendency  to  deep-seated 
inflammation,  exfoliation  of  the  epitheliiun,  exposm-e  and  involvement 
of  the  fibrous  submucosa  and  extension  into  the  periurethral  tissues, 
and  finally  the  nature  of  the  infection,  particularly  the  gonococcal  and 

1  Pedersen,  V.  C:  Jour.  Am.  Med.  Assn.,  .January  1,  1910,  liv,  29-33. 

2  Pedersen,  V.  C:    Diagnosis  of  the  Male  Urethra,  Arch,  of  Diag.,  October,  1910. 


STRICTURE  OF  THE  URETHRA  335 

the  suppurative  nongonococeal.  Tlie  exciting  loc;iJ  causes  are  either 
bacterial,  as  just  stated,  in  frequent  uncured  and  untreated,  mis- 
treated and  overtreated  attacks  of  any  of  the  severe  infections,  notably 
gonococcal,  or  traumatism.  The  traumatism  may  be  physical  from 
falls,  blows,  rough  and  oversized  instruments,  chemical  from  concen- 
trated irrigations,  instillations  and  applications,  thermic  from  hot 
fluids  or  instruments  and  electrical  from  the  Oudin,  d'Arsonval  and 
other  high-potential  currents.  Pressure  from  periurethral  inflammation 
and  neoplasm  and  obstruction  of  congestion,  edema  and  intraurethral 
new  growth  may  be  direct  exciting  causes. 

The  writer  had  a  case  of  traumatic  stricture  of  the  urethra  from  a 
chemical  burn,  followed  by  a  complete  cast  of  the  canal  about  five 
inches  long  and  later  by  complete  fibrosis  of  the  canal  for  this  distance 
with  the  caliber  of  No.  23  French.^  Fig.  75  shows  this  slough  with  a 
wire  passed  through  it  and  dried  in  alcohol  as  preserving  fluid. 

A  very  clear  statement  of  the  etiology  of  stricture  of  the  male  urethra 
is  given  by  G.  Frank  Lydston  as  follows:^ 

"1.  Pressure  from  without,  due  to  {a)  neoplastic  formation;  (h) 
extravasations  of  blood  or  urine  from  injury;  (c)  purulent  collections 
and  infiltrations;  {d)  fracture  of  the  pelvic  bones. 

2.  Spasm  of  the  muscles  in  and  about  the  urethra,  due  to  (a)  direct 
irritation  by  lesions  of  the  canal ;  (6)  reflex  irritation  from  more  or  less 
remote  pathological  conditions;  (c)  the  introduction  of  instruments; 
{(1)  emotional  excitement;  (e)  malaria  (?);  (/)  highly  acid  and  concen- 
trated urine,  and  occasionally  oxaluria  and  gravel. 

3.  Congestive  or  inflammatory  engorgement  of  the  urethra,  due  to 
(a)  acute  urethritis;  (6)  traumatism  of  the  urethra;  (c)  inflammation 
in  and  about  organic  obstructions. 

4.  Thickening  of  the  urethral  walls,  due  to  (a)  congestive  and  gran- 
ular patches  in  the  mucous  membrane,  i.  e.,  superficial  infiltration 
from  chronic  inflammation;  (6)  plastic  infiltration  and  formation  of 
connective  tissue  in  the  meshes  of  the  corpus  spongiosimi  from  severe 
and  long-continued  inflammation;  (c)  cicatricial  deposit  in  the  corpus 
spongiosum  and  lu-ethral  walls  incidental  to  traumatism;  {d)  cicatricial 
deposit  incidental  to  the  action  of  various  caustics  and  powerful 
irritants;  (e)  cicatricial  deposit  incidental  to  ulcerations  or  sloughing 
from  impaction  of  foreign  bodies. 

5.  Deficient  elasticity  of  the  uretlii-al  walls  and  corpus  spongiosum — 
(a)  from  congenital  sparsity  of  elastic  and  musciflar  fiber  and  a  pre- 
ponderance of  fibroconnective  tissue;  (6)  from  inflammation. 

6.  Congenital  narrowing  or  slight  atresia  of  the  lu-ethra  from  defec- 
tive fetal  development. 

7.  Polypi  of  the  uretliral  mucous  membrane." 

From  a  clinical  standpoint  strictures  may  be  divided  as  regards 
their  origin  into  (1)  congenital;  (2)  acquired;  (a)  traumatic;  (6)  chemical; 

1  Pedersen,  V.  C:  New  York  Med.  Jour.,  May  25,  1912. 

2  An  American  Text-book  of  Genito-urinary  Diseases,  S;T)hilis  and  Diseases  of  the 
Skin,  Bangs-Hardaway,  1899,  p.  133. 


33G    COMPLICATIOXS  AND  SEQUELS  OF  CIlliOMC  VRETIIRITIS 

(c)  aciitf  iiiHiuniiiatory  or  coiii^cstivo;  {d)  clirciiir  iiillaiimiatory;  (e) 
neurotic. 

As  iviiiinls  tlu>  essential  contlition  jM-odnc-ini,'  the  ol)strnction  they 
may  be  divided  into— (1)  spasmodic;  (2)  congestive  or  intlmnmatory 
(circmiiscribeil  or  general);  (3)  organic  or  fibrous  (permanent),  i.  c, 
neo]-)lastic." 


V  E  R  U  M  O  N^ 
TANUM 


1.  MEM  BRANOUS 
PORTION 


Fig.  88. — The  male  urethra  laid  open  on  its 
anterior  surface.     (Gray.') 


Fig.  89. — Thread-like  stricture 
invoh-ing  only  a  portion  of  the 
circumference  of  the  urethra. 
(Taylor.2) 


Pathology  of  Stricture. — ]\rany  features  of  the  pathology  of  stricture 
have  been  described  luider  pathology  of  chronic  lu'ethritis  on  page  205, 
and  Avill  therefore  need  only  allusion.  In  children  and  adults  the  under- 
lying conditions  are  much  the  same,  and  at  their  final  basis  chronic 
productive  inflammation.    Stricture  in  the  female,  so  far  as  closure  of 

*  Gray's  Anatomy.  20th  ed.,  1918.         ^  Genito-Urinarj'  and  Venereal  Diseases,  1904. 


STRICTURE  OF  THE  URETHRA 


337 


the  canal  is  concerned,  is  almost  unknown,  because  the  canal  represents 
the  posterior  urethra  of  the  male,  which  is  the  most  dilatable  portion 


Fig.  90. — Showing  firm  fibrous  stricture 
in  the  middle  of  the  pendulous  urethra, 
dilatation  of  the  canal  beliind  it,  nodular 
stricture  of  the  bulb,  abscess  of  the  pros- 
tate, hypertrophy  of  the  bladder  and 
dilatation  of  orifices  of  the  iireters. 
(Taylor.) 


Fig.  91. — Showing  a  dense,  fibrous  stric- 
ture of  the  urethra  just  beyond  the  peno- 
scrotal angle,  -«dth  dilatation  of  the  bvil- 
bous,  membranous  and  prostatic  urethrae. 
The  pendulous  lurethra  is  also  much  thick- 
ened and  infiltrated.  The  walls  of  the 
bladder  are  much  hypertrophied,  and  the 
orifices  of  the  ureters  dilated.     (Taylor.) 


and  never  closed  by  ordinary  endom-ethral  conditions,  although  the 
inflammatory  infiltration  and  all  other  featm'es  of  strictm-e  may  be 
present. 

22 


Tlie  patlioloirical  ^■:n•icties  are  two:  .coiiironital  and  acquired. 

Congenital  Stricture. — Congenital  strictmrs  are  snmnied  up  as 
atresia  or  malformation  of  embryologic  origin,  to  whith  subject  they 
strictly  belong. 

Acquired  Stricture. — Acquired  strictures  are  either  inflammatory  or 
tramnatic  and  practically  the  same  because  inflammation  is  produced 
by  severe  injury.  The  pathology  of  acquired  stricture  includes  that 
of  the  causal  conditions  already  named,  which  must  be  omitted 
as  foreign  to  this  book.  The  pathogenic  relation,  however,  must  be 
mentioned  and  remembered  between  stricture  and  such  conditions  as 
periurethral  neoplasm,  extravasation,  abscess  and  fracture  and  cndo- 
m-ethral  polypi. 

Organic  Stricture. — The  pathology  includes  that  of  all  other  forms  in 
one  or  more  of  their  details.  The  essence  is  a  cicatrix  resulting  from 
chronic  productive  inflammation  and  followed  by  secondary  contrac- 
ture, retracture,  deformation  and  obstruction  all  in  varying  degree 
and  extent  from  moderate  to  tight  closure  and  from  small  to  large 
portions  of  the  canal.  The  location  is  in  the  mucosa,  submucosa, 
corpus  spongiosmn  and  even  periurethral  tissues,  with  a  distribution 
at  one  point  or  many  points,  with  about  60  per  cent,  of  all  forms 
between  the  bulb  and  the  penoscrotal  angle.  The  tissues  involved  are 
the  mucosa  in  its  epithelimn,  glands  and  vessels,  the  submucosa,  the 
corpus  spongiosmn  and  periiu'cthral  structures  in  their  fibrous  basis. 
The  mucosa  in  its  epithelimn  is  exfoliated  or  denuded  into  an  ulcer 
which  does  not  heal  without  involvement  of  the  deeper  structures. 
About  this,  desquamation  may  be  active  and  constant,  accounting  for 
the  abundance  of  epithelial  cells  in  the  discharge  of  stricture  cases. 
The  glands  and  follicles  are  overactive,  hyperemic  and  h;vT^ertrophied 
with  abundant  thick  discharge  or  atrophied  by  loss  of  lining  or  by  pres- 
sure of  connective  tissue  deposits.  Surrounding  glands  take  up  com- 
pensatory function  in  order  to  maintain  the  moisture  and  thus  slugs 
of  mucus  and  shreds  are  often  produced.  The  bloodvessels  are  hyper- 
emic in  acute  and  multiplied  in  chronic  phases,  causing  again  changes 
in  the  epithelium,  glands  and  fibrous  tissue.  Diapedesis  of  leukocytes 
is  common  during  acute  periods.  Discharge  associated  with  stricture 
is  therefore  the  rule  and  comprised  of  pus  and  mucus,  fluid  or  coagulated 
into  shreds,  white  blood  cells  in  various  degrees  of  degeneration  and 
occasionally  red  cells. 

The  submucosa  is  thus  laid  bare  in  superficial  or  deep  ulcer,  accom- 
panied by  small  cell  infiltration,  spindle  cell  new  fibrous  tissue  and 
followed  by  dryness,  retraction,  contraction,  deformation,  narrowing 
and  obstruction.  The  first  three  of  these  processes  are  inherent  in 
new  fibrous  tissue  anj'^vhere  in  the  body  and  the  last  three  are  its 
essential  sequels  in  any  canal  of  the  body. 

The  corpus  spongiosmn  and  periurethral  tissues  are  invaded  in 
exactly  the  same  manner  by  strictures  of  marked  degree  without  or 
with  complications,  so  that  much  of  the  substance  of  the  corpus  may 
be  replaced  by  dense  cicatrix. 


nr^l;  ^2:~^o™Pl^cations  of  stricture.  Strictures  are  shown  in  the  penile  and  bulbous 
i^etnra  path  thickening  of  the  mucosa,  enlargement  of  the  mucous  cr^-pts  and  behind 
tne  stnctures,  dilatation  and  profound  changes  in  the  walls  of  the  can^.  The  bladder 
waus  are  densely  hypertrophied  to  many  times  the  normal  thickness  and  trabeculations 
d.re  uistinct.     (iaylor.i) 

1  Loo.  cit. 


340     COMPLICATIOXS  AXD  SEQUELS  OF  CITROXTC  URETHRITIS 

The  temporary  lesions  are  hyperemia,  catarrh  and  mild  suj)puration 
about  and  upon  the  strietm-e  substance.  These  may  light  uj)  under 
provocation  of  even  mild  degree  to  an  edema  which  will  close  the  canal 
acutely,  resulting  in  the  edematous  or  so-called  "inflannnatory"  stric- 
ture. On  the  other  hand,  these  temjiorary  lesions  may  ulthnately  be 
fully  cured. 

The  permanent  lesions  are  the  cicatrix  itself  and  the  ])rofound  changes 
which  its  obstruction  and  associated  infection  may  produce  proximal 
to  it  in  the  urethra  and  its  adjacent  glands  and  even  in  the  urinary 
system  from  the  bladder  to  the  kidneys.  Such  outcomes  may  be 
either  complications  or  sequels  of  the  stricture  or  associated  conditions 
marking  the  severe  jirocess  which  causes  the  stricture. 

The  complicating  and  associated  lesions,  occurring  rarely  in  con- 
genital but  more  conunonly  in  acquired  stricture,  are  in  fact  ascent  of 
the  hydraulic  back-pressure  of  the  stricture  and  its  infection  either  by 
continuity  of  the  mucosa  which  lines  these  organs  and  channels  as  a 
whole  system  or  through  the  bloodstream  by  metastasis.  There, 
therefore,  occur  in  highly  diverse  relations  and  degrees  urethritis, 
prostatitis,  hypertrophy,  dilatation,  atony  and  inflammation  of  the 
bladder,  ureteritis,  pyelonephritis  and  septic  absorption. 

The  urethritis  may  be  rather  benign,  as  overactivity  of  the  glands 
to  compensate  for  those  destroyed,  or  severe,  with  proximal  to  the 
stricture,  dilatation,  hypertrophy  and  atony  of  the  membrane  and 
its  muscles,  chronic  glandular  infection,  overactivity  and  atrophy. 
Ulcer,  concretion  and  abscess  are  not  rarities  and  even  fistuLne  with 
perineal,  scrotal,  gluteal,  femoral  and  abdominal  outlets.  The  pros- 
tatitis may  be  of  the  follicular  type  with  exfoliation  of  the  lining  epi- 
thelimu  or  more  profound,  of  the  glandular  or  parenchymatous  form 
with  single  or  multiple  relapsing  or  chronic  abscesses.  In  the  bladder 
the  wall  is  hypertrophied  by  resistance,  then  dilated  by  distension  and 
finally  atrophied.  Retention,  decomposition  and  infection  of  the  urine 
next  follow,  chiefly  by  the  Bacillus  coli  communis.  On  the  other  hand, 
the  gonococcal  infection  with  its  pyogenic  allies  ma}^  extend  from  the 
urethritis  directly  into  the  bladder.  The  ureters  become  involved  by 
parallel  processes  when  the  back-pressure  overcomes  the  bladder  wall 
and  causes  them  to  dilate  and  transfer  the  hydraulics  of  the  whole 
condition  and  the  infection  to  the  pelvis  and  even  substance  of  the 
kidney.  Thus  the  entire  urinary  system  from  the  point  of  stricture  to 
the  kidney  may  show^  any  or  all  the  foregoing  lesions  in  a  highly  com- 
plex picture,  which  needs  no  fiu"ther  details. 

Inflammatory  Stricture. — The  pathology  is  usually  temporary  in 
the  form  of  congestion  and  edema  as  separate  processes  or  added  to 
an  organic  fibrous  stricture  or  as  the  introductory  stage  of  the  latter, 
thus  j)roducing  acute  obstruction.  The  term  inflammatory  stricture 
is  misleading  through  confusion  with  the  inflammation  underlying 
all  strictm-e,  so  that  perhaps  the  term  edematous  stricture  would  be 
more  accurate.  As  just  indicated,  this  edema  may  occlude  the  urethra 
but  may  subside  and  lead  to  no  other  process  or  it  may  appear  on  the 


STRICTURE  OF  THE  URETHRA  341 

surface  or  annexa  of  an  organic  stricture  whose  small  lumen  may 
thereby  be  made  impassable.  Thus  an  organic  stricture  may  have 
edema  as  a  temporary  and  relapsing  element  appearing  under  the  least 
exciting  factor. 

Edematous  or  so-called  inflammatory  stricture  may  be  engrafted  on 
any  of  the  other  forms  or  through  faulty  instrumentation  be  of  itself 
a  clinical  entity.  Its  lesions  are  much  like  those  of  organic  stricture 
except  that  it  arises  quickly  to  its  full  degree  of  closure  and  has  rela- 
tively few  signs  of  inflammation  such  as  discharge.  It  is  never  a  chronic 
condition  or  chronic  obstruction  in  the  exact  meaning  of  these  terms. 

Spasmodic  stricture  does  not  possess  a  true  pathology,  in  that  it 
arises  from  muscular  response  to  psychic  inhibition  during  fear  or 
emotion,  to  spinal  inhibition  during  various  organic  disease  of  the 
cord  and  finally  to  local  irritation  through  offense  of  instriunents, 
instillations,  applications,  gravel,  hyperacidity  and  hyperalkalinity  of 
the  urine  and  toxemias,  as  of  malarial  origin. 

Stricture  by  external  pressure  shows  the  pathology  of  the  pressure, 
chiefly  in  circulatory  congestion,  edema  and  the  like,  added  to  and 
subsequent  to  the  pathology  of  the  causative  factors,  as  enumerated 
in  the  paragraphs  on  etiology  on  page  350.  Lack  of  space  forbids 
minute  discussion  of  the  pathology  of  the  causative  factors. 

Traumatic  Stricture. — Commonly  in  traiunatic  stricture,  especially 
those  due  to  chemical  and  thermal  sources,  the  infiltrating  inflammation 
is  in  the  entire  chcumference  of  the  canal  and  along  a  considerable 
extent.  It  is  for  this  reason  that  this  type  of  stricture  is  most  profound 
in  its  pathology,  far-reaching  in  its  results,  intractable  to  treatment 
and  prone  to  relapse,  because  the  mucosa  as  a  whole  instead  of  being 
deeply  damaged  in  one  or  more  separate  parts  and  a  small  extent  and 
little  depth  of  the  canal,  is  obliterated  and  replaced  by  dense  scar. 

The  forms  of  acquired  strictiu-e  are  annular,  diaphragmatic,  vah^ular 
and  bandlike.  The  annular  or  ring-form  type  are  chiefly  meatal,  with 
centric  opening  very  small  or  only  slightly  reduced,  and  may  be  the 
sign  of  true  atresia.  The  diaphragmatic  obstruction  is  a  little  like  the 
hymen  in  woman,  and  comprised  of  a  fold  of  mucosa  at  the  meatus, 
lacuna  magna  or  bulb,  affords  partial  definite  obstruction  and  has 
centric  or  eccentric  liunen.  Valvular  narrowing  consists  of  trans- 
verse folds  at  almost  any  point  of  the  urethra,  but  chiefly  the  prostatic 
urethra  and  at  the  penoscrotal  angle.  Bands  may  have  ahnost  any 
form  and  situation,  with  little  clinical  influence. 

Chronology  of  Stricture. — This  varies  with  the  form.  Edematous,  or 
so-called  "inflammatory"  stricture,  may  arise  quickly  in  the  midst 
of  almost  any  acute  urethral  lesion  and  may  itself  be  added  as  an  acute 
process  in  the  surface  or  annexa  of  organic  stricture.  These  facts  are 
responsible  for  the  misapprehension  among  the  laity  and  profession 
alike  that  stricture  is  a  rapid  process  and  often  lead  to  premature  and 
injudicious  treatment  of  such  an  infiltration  and  thereby  it  is  con^-erted 
from  a  temporary  to  a  permanent  condition.  Organic  strictm-e  of 
infectious  origin  is  ordmarily  a  very  slow  process,  exactly  like  all  other 


342    COMPUCATIOXS  AXD  SEQUELS  OF  CHRONIC  URETHRITIS 

scar  tissue.  If  the  infection  actively  continues  alony  with  the  chronic 
])roductive  inflanunation  in  the  stricture  then  the  hitter  may  be  rehi- 
tively  rapid,  ap])carinij:  in  a  few  months  instead  of  years.  This  is  often 
the  outcome  of  the  irritation,  with  instruments  of  eih'matous  strictiu'e, 
by  continuance  of  the  inflanunation  and  addition  to  the  scar  tissue. 
Total  obstruction  in  orjjanic  stricture  is  almost  always  slow  unless  the 
element  of  edema  is  at  any  time  added,  as  just  noted.  Organic  stricture 
of  traumatic  oriuin,  on  tlie  other  hand,  may  be  not  only  rapid,  but  also 
concomitant  with  the  healing  of  the  injury,  which  may  leave  a  scar  or 
infolding  of  the  mucosa  and  obstruction  in  high  degree.  The  progress 
of  strictiu'e  due  to  neoplasms  and  similar  conditions  rests,  of  course,  on 
the  nature  of  such  antecedent  element. 

The  i)athology  of  extravasation  of  urine  and  blood  as  a  complication 
of  stricture  is  dealt  with  imder  this  heading  as  of  sufficient  imi)ortance 
for  a  special  section  of  this  chapter  on  page  421 . 

Caliber  of  the  Urethra. — The  normal  anatomical  narrowings  are  most 
important  and  should  never  be  forgotten.  Numerous  measurements 
have  been  taken  with  m'ethrometers,  bulb-sounds  and  casts  after  death, 
with  the  following  table  gi\en  by  Taylor^  as  an  accepted  average  of 
results: 

Length.  Diameter. 

Meatus,  7  to  9  mm 21  to  28  F. 

Fossa  navicularis,  10  to  11  mm 80  to  33  F. 

Middle  of  pendulous  portion,  9  to  10  nun 27  to  30  F. 

Bulb,  11  to  12  mm 33  to  36  F. 

Membranous  urethra,  9  mm 27  F. 

At  apex  of  prostate,  10  mm 30  F. 

Middle  of  prostate,  15  mm 45  F. 

Vesical  end  of  prostate,  11  mm 33  F. 

The  most  significant  feature  of  this  list  is  that  where  the  urethra 
passes  through  the  triangidar  ligament,  as  the  most  fixed  tissue  in  its 
course,  its  average  diameter  is  No.  27  French.  It  is  consequently  a 
safe  rule  to  follow  never  at  first  to  pass  an  instrument  larger  than  No. 
26  or  27  French  until  the  resistance  offered  by  this  ligament  is  known. 
The  extremes  of  variation  in  the  meatus  from  No.  21  to  2S  French 
often  likewise  determine  the  size  of  instrument  acceptable.  A  most  sig- 
nificant fact  is  that  practically  all  subjects  ma>'  be  cystoscoped  and  ure- 
throscoped,  with  the  standard  instrument,  which  in  almost  all  designs 
is  No.  24  French  and  in  very  few  models  No.  26  French.  Behind  the 
meatus  comes  the  fossa  navicularis,  which  is  one  of  the  wide  portions  of 
the  canal  and  may  by  its  reduction  at  its  i)roximal  limit  deceive  the  un- 
wary into  the  diagnosis  of  stricture  at  that  point.  The  bulb  of  the  ure- 
thra is  another  very  wide  portion,  and  in  the  urethroscope  may  simulate 
many  of  the  folds  and  features  of  the  bladder  in  miniature.  It  may  be 
so  deep  a  pocket  as  to  catch  the  tip  of  the  soimd  in  its  proximal  portion. 
The  prostatic  urethra  in  the  male,  like  the  whole  canal  in  the  female, 
is  the  widest  and  most  dilatable  portion.    Thus  it  will  be  seen  that 

'  Genito-urinary  and  Venereal  Diseases,  3d  ed.,  p.  173. 


STRICTURE  OF  THE  URETHRA  343 

broadly  there  are  four  dilatations:  that  is,  in  the  fossa,  hulh,  membran- 
ous urethra  and  prostate,  at  each  extremity  of  which  there  arc  more 
or  less  distinct  narrowings.  These  normal  anatomical  narrowings, 
however,  differ  from  stricture  in  always  being  elastic,  readily  passable, 
promptly  resuming  their  former  caliber  and  free  of  the  usual  subjective 
and  objective  symptoms  of  stricture  and  its  associated  catarrh  or 
suppuration  of  the  mucosa. 

In  addition  to  these  normal  narrowings  the  mucous  membrane  is 
in  many  subjects  thrown  into  numerous  transverse  folds  not  unlike 
similar  folds  in  the  bowel,  notably  the  rectum.  They  may  be  suffi- 
ciently well  developed  to  engage  an  instrument  and  thus  simulate 
stricture,  so  far  as  a  slight  change  in  the  lumen  of  the  canal  is  con- 
cerned, but  the  absence  of  symptoms  of  stricture  establishes  their 
characteristics. 

From  the  foregoing  anatomical  arrangement  it  will  readily  be  judged 
why  strictures  are  so  apt  to  form  at  more  or  less  common  portions  of 
the  canal.  It  is  fully  accepted  that  the  reason  why  the  canal  from  the 
penoscrotal  angle  to  the  triangular  ligament  is  so  often  invaded  by 
stricture  is  that  the  pouch  of  the  bulb  more  or  less  persistently  pockets 
the  pus  and  the  normal  folding  or  constriction  of  the  urethra  at  the 
angle  retards  its  drainage.  Similarly  if  the  meatus  is  small  or  if  the 
mistake  of  wearing  cotton  over  it  is  employed,  the  pus  will  be  retained, 
penetration  of  the  mflammation  invited  and  stricture  ensue. 

Although  the  general  pathological  features  of  all  forms  of  stricture 
are  more  or  less  similar  and  although  the  same  observation  may  be 
properly  applied  to  the  symptom  complex,  it  is  nevertheless  better 
to  consider  the  clinical  features  of  each  important  variety  as  an  indi- 
vidual entity. 

Symptoms  of  Stricture. — Organic  Stricture. — ^The  clinical  picture  of 
stricture  provides  subjective  and  objective  systemic  and  local  condi- 
tions. In  the  average  case,  without  serious  complications  and  absorp- 
tion of  septic  products,  there  are,  strictly  speaking,  no  systemic  s^Tiip- 
toms  but  the  complicated  cases  in  which  the  proximal  urethra,  the 
prostate,  seminal  vesicles,  bladder,  ureters  and  kidneys  may  be  involved, 
may  present  many  or  any  of  the  local  or  general  symptoms  present 
in  profound  suppurative  disease  of  these  organs  as  stated  under  each. 
In  children  stricture  is  a  little  more  apt  to  be  congenital  or  traumatic 
and  in  adults  inflammatory  through  chronic  suppuration.  The  local 
subjective  symptoms  may  be  classified  (1)  as  those  arising  from  the 
urethra,  urinary  and  sexual  organs;  (2)  as  proceeding  from  the  ante- 
cedent inflammation;  (3)  those  due  to  the  obstruction  slowly  or 
rapidly  established;  and  finally  (4)  those  inherent  in  the  complications 
of  stricture. 

The  urinary  sjinptoms  comprise  the  first  thi-ee  items  of  this  list  and 
add  all  those  which  proceed  from  the  complications  and  sequels  of 
stricture  in  the  bladder,  ureters  and  kidneys.  The  first  group  is  there- 
fore described  with  the  urethral  s^onptoms  as  follow,  and  the  second 
group  will  be  dealt  with  under  complications  on  page  418. 


344     COMPLICATIONS  AXD  SEQUELS  OF  CIIROMC  URETHRITIS 

The  urethral  symptoms  are  discharge,  pain,  frequency  of  urination, 
obstruction  and  altered  stream. 

The  discharge  has  its  ori<j;in  in  the  urethral  ulands,  granulation 
tissue  about  the  stricture  and  the  uretlu-a  and  prostate  proximal  to  it. 
It  usually  appears  as  a  drop  in  the  mornuig  in  mild  cases  or  several 
times  during  the  day  in  more  marked  cases  and  is,  therefore,  of  very 
moderate  quantity,  as  a  rule,  in  uncom])licated  cases  but  copious  in 
complicated  cases.  Its  color  is  white  or  yellow  in  accordance  with  the 
presence  of  pus  mixed  with  the  mucus  and  its  constitutents  are  chieHy 
mucus,  pus  and  many  epithelial  cells,  as  described  on  page  270, 
exfoliating  from  the  surface  and  annexa  of  the  stricture. 

The  i)ain  is  due  to  the  open  lesions  usually  proximal  to  the  stricture, 
and  also  due  to  the  urethritis  and  urethrocystitis  accompanying  it 
and  to  the  stretching  of  the  mucosa  by  the  back-pressure  during 
uruiation.  It,  therefore,  occurs  during  this  act  and  is  usually  greatest 
in  cases  with  the  most  active  sign  of  inflammation  and  often  in  cases 
involving  the  bulb,  probably  because  the  urine  tends  to  stagnate  in 
the  bulb  and  cause  mflammation  there  and  in  the  proximal  portions 
of  the  canal.  In  degree  it  varies  from  mere  uneasiness  to  positive 
ardor  which  may  persist  for  some  time  after  urination,  especially  in 
the  victims  of  dribbling,  as  described  later. 

The  frequency  and  tenesmus  of  urination  are  based  on  the  irritation 
of  the  urethritis  in  and  about  stricture  and  of  the  urethrocystitis.  In 
uncomplicated  cases  the  granulation  tissue  around  the  stricture  if  in 
the  anterior  urethra  may  cause  a  diurnal  frequency  of  once  in  a  few 
hours  in  average  cases  only  slightly  above  the  normal,  or  once  hi  a 
fraction  of  an  hour  in  marked  cases,  especially  if  the  posterior  urethra 
and  neck  of  the  bladder  are  included.  In  complicated  cases  the  pros- 
tatitis, cystitis  and  other  higher  urinary  involvement  may  cause 
nocturnal  as  well  as  diurnal  frequency  of  aggravating  degree.  Natur- 
ally tenesmus  is  found  only  in  the  latter  type  as  it  rests  on  involvement 
of  the  sphincter  muscle  and  floor  of  the  bladder. 

The  foregoing  clinical  picture  is  classified  as  early  symptoms  in  that 
they  are  present  often  before  obstruction  is  great,  but  they  may  also 
mark  the  transitional  period  and  increase  with  the  degree  of  closure  of 
the  stricture. 

The  sense  of  obstruction  is  shown  by  the  added  effort  at  emptying 
the  bladder,  and  may  be  at  first  and  for  years  moderate,  and  hardly 
attract  the  patient's  attention.  It  may  slowly  progress  up  to  a  certain 
point  and  thereafter  rapidly  by  complications  and  sequels  until  a  high 
degree  of  closure  is  reached.  The  so-called  tight  strictures  which  permit 
only  a  filiform  to  be  passed  are  extreme  in  this  symptom  and  require 
a  muscular  effort  which  may  expel  flatus  from  the  rectum  and  may 
induce  or  increase  hernia. 

The  alteration  and  dribbling  of  the  urine  as  associates  of  the  obstruc- 
tion may  appear  late  or  early  among  the  subjective  signs.  A  meatus, 
large  normally  or  postoperatively^  will  flatten,  weaken  and  spread  the 
stream  much  as  the  flaccid  urethra  does  in  woman,  whereas  a  meatus. 


STRICTURE  OF  THE  URETHRA.  345 

small  normally,  or  by  stricture,  (compresses  the  stream  and  adds  to  its 
projection.  The  natural  narrowing  of  the  urethra  at  its  outlet  is  prob- 
ably for  the  purpose  of  projecting  the  outflow  away  from  the  body. 
.  The  stream  of  stricture  is  altered  in  initiation,  form,  maintenance, 
force  and  termination.  The  beginning  of  the  act  may  be  difficult  from 
the  resistance  or  reflex  irritation  proximal  to  the  narrowing.  Continua- 
tion of  the  stream  may  through  failure  of  the  bladder  force  or  otherwise 
be  interrupted  so  that  the  stream  begins,  stops  and  then  resumes. 
The  form  is  single,  twisted  and  spattering,  or  doubled,  forked  and 
broken.  The  force  may  be  little  changed  or  decreased  until  the  urine 
reaches  the  meatus  and  falls  vertically  from  it.  The  termination 
instead  of  prompt  dryness  of  the  parts  may  be  prolonged  into  drops  or 
moisture  for  several  moments  and  be  followed  by  a  drop  of  mucus  and 
pus.  S\ich  terminal  dripping  is  due  to  the  obstruction  and  the  pocket 
behind  it  combined  with  the  rigid,  inelastic  inflamed  walls  of  the 
urethra  and  weakness  of  its  muscle  coats. 

The  urinary  symptoms,  not  already  described  as  dependent  directly 
on  the  m-ethra,  are  chiefly  referred  to  the  bladder,  ureters  and  kidneys, 
practically  always  as  complications  and  sequels  of  stricture,  although 
the  same  severe  process  which  evolves  the  stricture  may  also  involve 
these  organs.  Such  symptoms  may,  therefore,  be  dismissed  as  the  same 
as  those  already  noticed  under  urethrocystitis,  cystitis,  ureteritis,  and 
pyelonephritis  in  the  subject  of  Complications  of  Gonococcal  Urethritis 
on  pages  163  to  188  and  again  in  Chapters  XIII,  XIV,  XV  and  XVI. 

The  sexual  symptoms  have  the  basis  of  irritation,  obstruction  and 
the  complications.  The  irritation  about  a  stricture,  especially  one  near 
the  posterior  urethra,  induces  increased  desire,  which  is  followed  either 
by  frequent  noctm-nal  emissions,  excessive  normal  intercom'se  or 
perversions.  The  discharge  of  semen  over  the  granulating  inflamed 
urethra  causes  ardor  and  the  muscular  action  of  ejaculation  and  dis- 
tention behind  a  tight  stricture  causes  pain  exactly  as  does  urination. 
In  marked  obstruction  retrograde  ejaculation  has  been  often  reported 
in  which  the  semen  is  discharged  into  the  bladder,  and  still  more  com- 
monly are  seen  patients  w^ho  do  not  ejaculate  externally  at  all  in  the 
true  sense,  but  whose  semen  is  later  washed  aw^ay  with  the  urine  after 
subsidence  of  the  turgescence  of  erection  and  intercourse.  Also  after 
repose  follow^ed  by  m-ination  the  stricture  again  opens  slightly.  It  is 
the  congestion  of  the  inflammation  and  the  stimulation  of  irritatmg 
elements  associated  with  strictiu-e,  which  both  locally  and  in  the  spinal 
cord  produce  increased  desire  and  frequent  erections  without  or  with 
the  presence  of  women.  Therefore,  men  with  strictm*e  working  in  the 
midst  of  women  are  not  infrequentl}^  literally  tortured  and  the  sexual 
excitement  alone  or  the  mental  impression  made  by  the  emissions, 
or  the  actual  presence  of  the  opposite  sex  or  all  three  combined  fre- 
quently lead  to  inordinate  practices.  As  a  rule,  emissions  being  reflex 
are  less  harmful  than  intercourse  or  perversions  which  are  intentional. 
The  tm-gescence,  however,  of  all  these  processes  adds  to  the  congestion 
and  inflammation  aromid  the  stricture  and  its  other  s^^nptoms  so  that 


34G    COMPLICATIONS  AXD  SEQUELS  OF  CHRONIC  URETHRITIS 

all  the  conditions  of  stricture  (le])en<lent  on  inflammation  are  apt  to 
be  increased. 

Another  sexual  sym])tom  is  chordee  and  e\en  incur\ation  in  inflamed 
irritable  strictures  with  nuich  urethritis  above  and  below  them.  As 
previously  noted,  this  is  a  symptom  of  urethritis  in  its  earlier  stages  so 
that  when  it  is  foimd  in  stricture  cases  it  is  to  be  accepted  as  the  index 
of  the  urethritis  rather  than  of  the  fibrosis  itself.  It  reaches  extreme 
develo])ment  in  incurvation,  which  is  usually  not  seen  unless  a  large 
portion  of  the  canal  has  been  changed  into  scar  tissue  and  thus  has  lost 
extensibility  and  distensibility,  and  thus  compels  the  corpora  caver- 
nosa to  incurvate  rather  than  distend  into  a  perfect  erection,  to  the 
great  discpiietude  of  the  })atient. 

The  sexual  complications  reside  in  the  seminal  vesiculitis,  relapsing 
epidid\TOOorchitis  and  ])rostatitis  and  do  not  dift'er  from  those  laid 
down  for  these  conditions  during  acute  and  chronic  urethritis  on  pages 
83  and  313. 

The  local  objective  sAinptoms  are  in  many  respects  the  same  as  the 
subjecti^•e  type  in  nature  and  origin,  and  comprise  chiefly  discharge, 
obstruction,  altered  stream  and  complications.  The  discharge  requires 
laboratory  examination  and  will  be  found  to  comprise  mucus,  pus  and 
epitheliinn  eacli  chiefly  ])redominant  or  all  variously  mixed  according 
to  the  acti^"ity  and  suppiu-ation  of  the  process.  The  gonococci  should 
always  be  searched  for  by  smear  and  culture  and  its  influence  on  the 
system  at  large  determined  by  the  complement  fixation  test.  Compe- 
tent bacteriologic  investigation  will  also  reveal  the  nature  of  other 
organisms,  such  as  catarrhal  and  pyogenic,  and  should  be  carried  out 
whether  the  discharge  is  free  or  not,  or  consisting  only  of  shreds  in  the 
urine,  collected  under  full  antiseptic  precautions. 

The  obstruction  is  revealed  by  the  altered  stream  and  by  external 
and  internal  ]jalpation.  Changes  in  the  stream  of  urine  observed  cor- 
roborate the  patient's  description,  but  the  projection  of  the  stream  is 
the  most  important  element  for  notice  as  it  indicates  the  patency  of  the 
stricture  and  the  condition  of  the  urethra  and  bladder  proximal  to  it. 
Visible  eft'ort  during  the  ejaculation  and  flatus  are  significant.  External 
examination  of  the  urethra  reveals  in  mild  cases  one  or  more  moderate 
thickenings  and  in  severe  cases  large  nodes  or  collars  with  dilatation 
and  h^-pertrophy  or  atony  of  the  urethra  behind  them.  Such  palpation 
may  also  bring  to  the  front  discharge  in  larger  than  usual  amount 
through  expression  of  the  mucous  follicles.  Patients  may  themselves 
show  the  sites  of  strictures  but  sometimes  do  so  anteriorly  to  the  real 
points  because  of  reference  by  the  nervous  system  of  the  symptoms 
toward  the  glans  penis. 

"^I'he  internal  examination  of  the  lu'cthra  is  carried  out  with  sounds, 
catheters,  bulbous  bougies,  whalebone  filiforms  and  the  urethroscope, 
and  varies  with  the  tightness  of  the  stricture;  in  other  words,  with  the 
severity  of  the  case.  In  open  strictures,  size  20  French  and  larger,  a 
round-])oint  sound  with  no  taper  is 'a  very  valuable  instrmnent  for 
demonstrating  the  situation  and  character  of  the  narrowing.    In  this 


STBlCrVRK  OF  rilK  (JIlErilRA  347 

particular  the  Beiiique  curve  instrument  is  extremely  advisable  as  it 
tends  to  accommodate  itself  to  alterations  in  the  proximal  urethra 
with  little  inconvenience  to  the  patient.  The  Bangs  syringe  sound 
may  be  employed  for  such  service  and  likewise  as  i)art  of  the  exploratory 
step  for  treatment  of  the  stricture  and  its  annexa  with  mild  solutions. 
The  round  points  of  these  instruments  are  relatively  difficult  to  insert 
so  that,  as  a  rule,  one  several  sizes  smaller  than  the  tapered  instruments 
is  available,  but  through  that  very  fact  it  will  often  locate  an  open 
stricture  which  the  tai)ering  bulbous  bougie  will  fail  to  discover.  With 
the  sound  or  the  Bangs  syringe  in  place,  careful  external  examination 
of  the  urethra  should  be  made  proximal  to  it  or  over  it  to  determine 
the  character  of  the  infiltration.  Catheters,  especially  lisle-thread 
and  silk  gum-elastic  catheters  may  be  employed  in  much  the  same 
manner,  especially  if  the  history  is  one  of  irritability  about  the  stricture, 
which  will  be  much  less  disturbed  by  flexible  than  by  rigid  instruments. 
To  the  same  service  the  various  conical  and  olive-pointed  bougies  and 
catheters  lend  themselves  but  somewhat  more  successfully  to  the  closed 
class  of  stricture. 

In  close  stricture,  that  is,  from  10  to  19  French,  inclusive,  the  bulbous 
bougie  is  the  instrument  of  choice  and  may  either  be  of  metal  or  gum 
elastic.  The  latter  is  to  be  preferred  in  every  way  because  this  degree 
of  narrowing  is  much  more  apt  to  be  associated  with  more  or  less  chronic 
inflammation,  if  not  infection,  whose  lesions  should  be  invaded  with 
great  gentleness.  They  are  made,  as  a  rule,  double  ended,  one  olivary 
and  the  other  conical,  of  which  the  former  is  the  better  to  use,  again 
for  the  reasons  that  it  does  not  dilate  so  readily  and  may  impinge  on 
the  anterior  surface  of  the  stricture  which  the  cone  would  otherwise 
pass.  Careful  palpation  of  the  urethra  proximal  to  a  bougie  which  has 
not  passed  the  stricture  and  distal  to  one  which  has  slipped  through, 
should  always  be  carried  out.  If  the  head  of  the  instrument  is  through 
the  stricture  it  should  be  drawn  back  until  it  engages  in  order  to  facili- 
tate such  study.  The  advantage  of  bulbous  bougies  over  soimds  for 
all  stricture  examination  is  that  they  will  more  readily  pick  out  the 
number  of  strictures,  whereas  a  sound  will  locate  only  the  closest  and 
may  slide  through  without  observation  others  that  may  be  slightly 
more  open. 

In  tight  strictures  the  whalebone  filiform  guide  is  the  only  mstru- 
ment  available  and,  like  the  sound,  will  locate  only  the  tightest  point 
through  which  it  may  or  may  not  glide.  On  account  of  the  inflamma- 
tion and  granulation  tissue  practically  always  around  a  tight  stricture, 
it  is  very  good  policy  to  flush  the  urethra  with  water  or  normal  salt 
solution,  hot  up  to  tolerance,  in  order  to  reduce  the  edema.  The 
urethra  may  also  be  filled  with  adrenalin  solution  for  five  or  ten 
minutes  with  the  same  purpose.  A  hot  sitting  bath  in  patients  who 
have  suddenly  had  an  edematous  or  inflammatory  strictm'e  engrafted 
on  the  right  lesion  through  debauchery,  mstrmnentation  or  other 
incident,  is  of  great  value  in  passing  the  lesion.  After  these  prelimi- 
naries filiforms  of  3,  4  and  5  French  diameter,  with  their  tips  left 


348     COMPLICATIOXS  AXD  SEQUELS  OF  CHROXIC  U  RET  I  IRITIS 

straight  or  variously  kinked,  are  passed  into  the  invtlira  one  after  the 
other  until  the  canal  is  full,  with  uiovenient  of  the  hlifornis  still  ])os- 
sible.  After  every  two  or  three  have  thus  been  inserted,  each  of  the 
whole  number  is  again  gently  manipulated  in  the  effort  to  engage  it 
in  the  narrow  and  usually  tortuous  canal.  There  are  very  few  strictures 
indeed  which  by  this  method  with  greatest  gentleness  and  })atience 
through  many  minutes  or  even  an  hour  are  im])assable.  It  is  safe  to 
say  that  a  stricture  which  is  perx'inus  to  urine  is  also  pervious  to  a 
filiform,  after  suitable  j^reparation  of  the  urethra  and  the  j^atient,  if 
in  the  hands  of  an  expert.  Roughness  in  any  degree  is  to  be  forbidden, 
as  it  instantly  adds  a  stricture  by  edema  to  the  condition  already 
existing. 

The  value  of  soimds,  catheters,  bougies-a-boule  and  filiform  guides 
in  the  treatment  of  stricture  is  described  on  pages  377  to  384. 

The  urethroscope  is  of  value  in  the  internal  examination  of  stricture 
of  open,  close  and  tight  varieties.  Instruments  of  the  Buerger  type 
with  a  lateral  window  are  available  in  studyhig  the  urethra  distal  to 
the  stricture  which  is  impassable  to  itself  and  the  urethra  proximal 
to  it  in  the  reverse  situation.  Instruments  of  the  Otis  type  with 
terminal  o])ening  and  either  extrinsic  or  intrinsic  illumination  are  of 
special  \a\ue  in  seeing  the  anterior  siu'face  of  close  or  tight  strictures 
which  the  window  of  a  Buerger  instrument  will  not  reach  on  account 
of  the  long  tip  which  accommodates  the  lamp.  Another  service  of 
this  form  of  urethroscope  is  an  aid  in  the  introduction  of  filiform  guides. 
Occasionally  the  linnen  of  a  stricture  may  be  located  with  the  lu'ethro- 
scope,  decongesting  applications  made  directly  to  its  surface  and  a 
filiform  passed  through  it  under  the  eye  when  previous  efforts  have 
failed.  Availability  of  the  urethroscope  for  the  treatment  of  stricture 
is  dealt  with  on  page  393. 

The  objective  sexual  symptoms  frequently  have  no  definite  basis; 
on  the  other  hand,  the  conditions  underlying  them  already  described 
under  subjective  phenomena  may  be  proved  by  careful  examination 
especially  with  the  urethroscope.  For  this  reason  every  victim  of 
pronounced  sexual  acti^'ity  through  his  stricture  should  receive  a 
careful  examination  with  this  instrument.  Likewise  the  relation  of 
complications  with  this  variety  of  symptoms  must  not  be  omitted. 

The  objective  complications  duplicate  those  given  under  this  sub- 
jective heading  and  will  need  no  further  details  than  those  portrayed 
in  Chapters  II  and  A'  for  the  same  conditions  arising  from  urethritis  in 
acute  or  chronic  form. 

Rectal  examination  in  stricture,  with  and  without  instruments  in 
the  urethra,  should  never  be  omitted  except  in  the  simj^le  uncompli- 
cated cases,  and  in  these  it  is  good  judgment  to  employ  it  as  the  final 
step  of  diagnosis.  Frequently  in  no  other  way  may  the  condition  of  the 
urethra  immediately  about  the  triangular  ligament,  the  bulb  in  front 
of  it  and  the  prostate  behind  it  be  fully  made  out.  Previously  unsus- 
pected complications  reveal  themselves  to  this  step  and  the  density, 
irritability  and  discharge  of  the  stricture  are  readily  developed. 


STRICTURE  OF  THE  URETHRA  349 

Inflammatory  or  Edematous  Stricture. — As  previously  noted  linder 
pathology,  stricture  by  edema  is  usually  a  factor  added  to  one  of  the 
other  forms,  either  in  the  course  of  the  inflammation  itself  or  in  virtue 
of  irritation  by  instruments,  applications  or  d(;bauch.  In  a  certain 
sense  it  is,  therefore,  both  inflammatory  and  traumatic.  In  the  latter 
case  it  may  sometimes  be  seen  in  a  relatively  normal  urethra  which 
has  been  explored,  treated  or  urethroscoped  with  undue  violence  or 
frequency  and  it  is  a  very  common  temporary  outcome  of  dila- 
tation treatment  of  stricture  carried  on  in  steps  too  large  anrl  fre- 
quent. The  subjective  facts  are  those  of  sudden  incidence  of  one  of 
the  foregoing  factors  on  an  antecedent  basis.  The  patient  is  suddenly 
unable  to  pass  water  sometimes  within  a  very  brief  period  of  time  or 
during  a  few  hours  after  instrumentation.  The  objective  features  are 
that  urination  commonly  supervenes  upon  the  application  of  a  hot 
sitting  bath,  hot  urethral  irrigation  and  the  gentle  instillation  of 
adrenalin  chlorid  as  decongestants.  The  suggested  diagnosis  of  edema 
precludes  urethral  investigation  until  its  subsidence  and  then  with 
great  gentleness  it  is  advised  in  order  to  find  the  cause  of  the  outbreak. 

Spasmodic  Stricture. — As  in  other  forms  of  stricture,  we  may  distin- 
guish subjective  and  objective  signs.  There  is  the  history  of  sudden 
and  even  repeated  previous  attacks  with  few  sjnnptoms  and,  as  a  rule, 
only  temporary  closure,  as  the  spinal  cord  compels  the  spasm  to  dis- 
appear as  soon  as  the  bladder  is  greatly  filled.  On  the  other  hand,  there 
is  spasm  of  the  sphincter  muscle  dependent  on  organic  disease  of  the 
spinal  cord  which  does  not  so  relax  and  may  lead  to  overdistention  and 
atony  of  the  bladder  miless  relieved  by  passing  a  catheter  or  supra- 
pubic acupuncture.  Some  patients  have  spinal  spasmodic  closure  of 
the  rectum  and  cannot  defecate  at  the  same  time  and  all  present  more 
or  less  the  picture  of  profound  mental  impression  rather  than  definite 
urethral  disease.  The  writer  recalls  one  of  his  patients,  a  young  neuro- 
pathic Hebrew  with  a  long  well-marked  history  of  masturbation,  who 
appeared  with  a  distended  bladder  and  rectum  which  he  had  not  been 
able  to  empty  for  eighteen  or  twenty  hours.  One  similar  attack  of 
shorter  duration  had  preceded  it.  Physical  examination  was  negative 
except  for  the  distended  bladder  and  a  prostate  edematous  by  pressure 
of  the  bladder,  as  there  was  no  element  in  his  story  to  correspond  with 
prostatic  congestion,  inflammation  or  relaxation.  A  soft  gum-elastic 
catheter  of  moderate  size  was  passed  with  great  deliberation  and  gentle- 
ness and  soon  overcame  the  spasm. 

A  larger  series  of  cases  of  spasmodic  stricture  occur  during  urethral 
manipulation  in  virtue  of  such  features  as  the  stretching  of  an  abnor- 
mally close  meatus  or  the  passing  over  granulation  tissue  or  the  engag- 
ing of  an  instrument  in  the  depth  of  the  bulb  of  the  urethra  instead  of 
passing  through  the  membranous  urethra  unimpeded.  The  patient 
usually  presents  a  nervous  expression  of  face,  rigidity  of  the  abdominal 
muscles  and  e\'en  of  the  sphincter  ani  through  which  the  finger  passes 
with  difficulty  for  exploration  of  the  bulb  and  guidance  of  the  tip  of 
the  instriunent  through  the  membranous  urethra.     It  is  commonly 


350     COMPLICATIOXS  AXD  SEQUELS  OF  CIIROXIC  VRETtJRlTlS 

at  this  point  that  the  spasm  befjins  to  manifost  itself  witli  involvement 
of  the  sphincter  vesicte  iinally.  A  consultation  case  of  the  writer  yve- 
sented  a  man  whose  physician  after  a  successful  relief  of  a  gonococcal 
acute  urethritis  had  been  unable  to  pass  a  sound  after  several  normal 
attempts.  The  feat  was  easily  accomiilished  after  noting  that  the 
tip  of  the  instrument  seemed  to  ])resent  in  the  perineum  where  sup- 
port with  the  finger  uj^on  the  external  surface  lifted  the  sound  into 
the  membranous  and  prostatic  lu'ethra  where  it  encountered  spasm  at 
the  neck  which  easily  yielded  to  pressure  by  the  weight  of  the  sound 
itself  within  about  ten  minutes. 

The  objective  s>'mi)toms  are.  therefore,  the  ner\()us  beha\ior  of  the 
patient,  the  fact  or  history  cf  a  good  stream  on  other  occasions,  absence 
of  inflammation  in  the  urethra,  and  during  the  examination  rigidity  of 
the  abdominal  and  anal  muscles.  A  point  of  obvious  irritability  as 
the  sound  ])rogresses  or  encountered  with  the  bougie-a-boule  is  very 
important  and  study  of  it  by  the  urethroscope  should  at  once  follow. 

Stricture  by  Periurethral  Pressure. — As  already  indicated,  strictin-e 
by  extraiuethra  pressure  may  arise  from  new  growth,  extravasation, 
abscess  and  fracture  of  the  bones  of  the  peh'is,  whose  action  is  essen- 
tially obvious  in  direct  focal  compression  of  the  canal.  According  to 
the  cause  the  closure  has  relatively  slow  subjective  symptoms  in  new 
growth  and  in  abscess  unless  occasionally  in  the  former  and  more  fre- 
quently in  the  latter  the  element  of  edema  is  added,  when  rapid  onset 
may  ensue.  Extravasation  of  blood  and  fracture  produce  at  times 
sudden  closure  directly  or  by  early  secondary  edema  and  are,  therefore, 
the  sources  of  acute  stricture  in  these  classes  of  cases.  The  objective 
local  s^Tnptoms  afford  the  signs  in  the  perineum  and  rectiun  of  neo- 
plasm or  abscess  of  the  prostate  and  of  the  accumulation  of  blood  and 
urine  and  the  displaced  bone.  The  value  of  the  .r-ray  in  the  latter  is 
apparent.  The  slower  forms  of  stricture  of  this  type  may  be  explored 
by  bougies-a-boule,  catheters  and  dilators  and  whalebone  filiform 
guides — all  flexible  by  choice,  and  used  with  great  deliberation.  Steel 
sounds,  silver  catheters,  cystoscopes  and  urethroscopes  are  to  be  used 
with  reserve.  The  open-end  urethroscope  may  be  passed  down  to  the 
face  of  the  obstruction  for  study.  The  obvious  appearance  of  edema 
as  the  source  of  strictiu-e  supervening  on  the  foregoing  factors  may  be 
pro\-ed  by  the  steps  hereinafter  stated,  namely,  of  suitable  external 
and  internal  applications  of  heat  and  mild  astringents. 

Traumatic  Stricture. — The  results  of  accident  are  chiefly  urethral 
and  urinary  and  may  develop  the  subjective  and  objecti^'e  local  signs 
immediately  after  the  injury  in  virtue  of  the  trauma  itself  or  of  the 
imperfect  manner  of  healing  of  the  canal  or  both  combined.  On  the 
other  hand,  it  may  be  a  late/  development  after  the  tear  has  closed  and 
arise  from  the  urethritis  w-hich  the  deformity  of  the  canal  excites. 
Such  a  traumatic  stricture  becomes  indubitably  inflammatory,  under 
which  heading  all  strictures  by  injury  may  be  classed  because  injury- 
excites  inflammation.  Traumatic  strictures  are  for  the  most  part 
tight  or  filiform,  that  is,  9  French  and  smaller  and  therefore  have  a 


STRICTURE  OF  THE  URETHRA  351 

definite  train  of  symptoms  and  a  dense  fibrosis  as  a  patliogenesis. 
Sexual  symptoms  are  more  rare  than  in  organic  stricture  until  the 
closure  becomes  great  or  unless  urethritis  is  a  feature,  romplications 
are  still  more  rare  in  this  type  of  stricture  because  the  nature  of  its 
origin  compels  the  victim  to  seek  aid  earlier  than  in  other  cases  of 
organic  closure.  The  objective  local  symptoms  may  be  external  scar 
and  deformity  or  other  signs  of  injury,  more  usual  in  postoperative 
stricture  than  other  forms  which  not  infrequently  are  without  external 
signs  or  violence.  The  history  will  guide  as  to  the  focal  point,  which 
may  be  proved  by  exi:ernal  and  rectal  palpation.  The  other  steps  of 
the  examination  are  the  same  as  those  laid  down  for  organic  stricture 
and  the  instruments  are  chosen  in  accordance  with  the  expected  caliber 
of  the  canal  and  the  signs  of  irritation  and  inflammation  with  definite 
tendency  to  favor  soft  and  flexible  instruments. 

Termination  of  Stricture. — The  general  termination  and  results  of 
stricture  respect  the  urethra,  sexual  and  urinary  organs  and  life. 

Organic  stricture  in  its  prognosis  sums  up  that  of  all  the  other  forms 
in  their  severe  degree,  and  rests  on  the  closure,  surrounding  urethritis, 
complications  and  treatment  as  the  chief  elements.  Open  strictures 
are  practically  nodes  or  infiltrations  usually  without,  occasionally  with, 
urethritis,  have  few  dangers,  little  influence  on  the  urinary  stream 
and  a  good  prognosis,  unless  the  passing  of  sounds  is  violent  in  over- 
distention  and  frequent  in  interval,  which  will  convert  such  a  stricture 
into  a  progressing  fibrosis  and  ultimately  a  tight  and  complicated  stric- 
ture. Elastic  strictures  of  this  degree  are  cured  only  by  m-ethrotomy 
through  all  their  fibers  with  subsequent  dilatations  occasionally  to  pre- 
vent recontraction.    Unless  the  division  is  thorough  relapse  is  prompt. 

Close  strictures  present  urethritis  as  a  definite  factor  whose  bacteri- 
ology is  important  in  the  prognosis.  Instruments  may  excite  and  extend 
the  inflammation  and  thus  indirectly  or  directly  by  their  own  trauma 
add  to  the  stricture.  The  tendency  to  strain  of  the  bladder  and  to 
infection  of  the  upper  urinary  tract  is  in  these  strictm'es  a  definite 
factor  and  is  the  real  danger  of  these  cases.  The  urethritis  is  a  com- 
plication of  these  strictures  which  may  persist  even  after  their  dilata- 
tion and  division,  so  that  suitable  aftertreatment  thereof  determines 
the  end  result.  Tight  strictm-es,  often  tortuous  and  extensive,  are 
always  associated  with  urethritis  and  its  complications  in  the  mucosa 
proximal  to  the  obstruction  and  not  infrequently  may  have  profound 
lesions  of  the  bladder  and  kidneys.  After  the  strictm-e  has  been  relieved 
all  these  conditions  may  persist  and  relapse  in  themselves  as  patho- 
logical entities  and  tend  to  induce  definite  retm'u  of  the  stricture.  It 
is  these  cases  in  which  cutting  operations  must  drain  the  bladder  and 
urethra  and  in  which  the  appearance  of  sudden  obstruction  by  edema- 
tous strictm-e  after  debauch  or  neglect  may  suddenly  break  do"v^^l  the 
diseased  kidney  and  cause  uremia  and  death.  Edematous  stricture 
added  to  a  complicated  tight  fibrous  stricture  is,  therefore,  a  dangerous 
condition  and  may  readily  excite  extravasation,  infection,  sepsis  and 
death. 


352      COMPLICATIOXS  AND  SEQUELS  OF  CHRONIC  URETHRITIS 

FAlcniatous  stricture  is  usually  an  acute  inflammatory  addondnm  to 
other  varieties.  It  is,  therefore,  conunonly  temporary  under  good 
treatment,  especially'  when  it  arises  de  novo  during  an  acute  urethritis. 
On  the  other  hand,  it  may  lead  to  extravasation  as  just  noted,  sud- 
denly closing  a  tight  organic,  traumatic  or  neoplastic  stricture.  In 
this  case  its  result  is  identified  with  that  of  the  secondary  condition 
of  urine  in  the  cellular  planes  and  with  the  renal  and  other  compli- 
cations. 

Spasmodic  stricture  is  a  reflex  condition  j)urcly  tem])orary  and  with- 
out significance  in  most  cases,  imless  associated  with  organic  s])inal 
disease  when  the  latter  itself  becomes  the  chief  agent.  This  condition 
is  not  the  concern  of  a  work  on  urology. 

Traumatic  stricture,  if  the  injury  to  the  m-ethra  is  slight,  may  be  of 
little  moment  but  the  reverse  is  usually  the  rule,  so  that  the  deformity 
and  dense  scar  of  the  laceration  in  the  urethra  make  this  form  among 
the  most  difficult  to  deal  with,  as  rapid  contracture  of  such  scars  in 
the  mucous  passages  of  the  body  is  the  common  experience.  Thus 
throughout  life  such  a  stricture  requires  regular  gentle  dilatation  in 
order  to  ]lre^■ent  unfa\orable  sequels  in  the  sexual  and  urinary  systems. 

Relapse  of  Stricture. — Relapse  of  stricture  in  the  sense  of  return  of 
the  obstruction  is  the  rule  under  neglect  of  suitable  aftertreatment 
by  passing  sounds  throughout  life  at  intervals  indicated  by  the  behavior 
of  the  band.  The  scar  tissue  of  the  stricture  cannot  be  removed  by  any 
o])eration,  as  even  plastic  repair  necessarily  leaves  its  own  cicatrix. 
Like  all  other  scar  tissue  in  the  body,  and  especially  in  mucous  mem- 
brane passages,  it  follows  the  one  course  of  contraction  which  can  be 
corrected  only  by  suitable  dilatation  and  it  is  exceptional  for  a  single 
operation  to  be  followed  b>'  lifelong  cure,  unless  periodic  soimding  is 
performed,  preferably  with  flexible  instruments  so  as  to  cause  the  least 
possible  distm'bance.  Relapse  of  the  complications  of  stricture,  both 
sexual  and  urinary,  is  also  common  owing  to  the  fact  that  the  obstruc- 
tion has  produced  a  mechanical  change  in  the  organs  and  passages  in 
addition  to  the  presence  of  infection.  The  causes  of  relapse  are  com- 
monly ill  health  and  the  presence  of  gout,  rhemiiatism,  sy])hilis,  tuber- 
culosis and  vicious  habits,  especially  alcoholic,  dietetic  and  sexual 
excesses.  Reciu'rence  is  less  likely  to  appear  in  the  anterior  urethra, 
especially  the  pendulous  portion,  but  much  more  apt  to  be  frequent 
and  prompt  in  the  bulbous  anterior  urethra  and  the  membranous  and 
prostatic  canal;  in  short,  where  the  relations  of  the  passage  are  most 
fixed  the  tendency  of  penetration  of  the  disease  is  greatest.  Moreover, 
in  the  pendulous  urethra,  drainage,  mobility  and  elasticity  of  the  canal 
are  well  dexeloped.  It  is  probable  that  in  this  portion  a  stricture, 
which  is  shown  b}^  the  urethroscope  to  have  been  thoroughly  divided 
so  that  a  band  no  longer  exists  and  the  mucosa  to  be  mobile  on  the 
tunica  albuginea  of  the  corpora  cavernosa,  may  be  pronounced  cured 
and  will  remain  cured.  On  the  other  hand,  where  these  findings  cannot 
be  established,  relapse  may  be  expected.  In  the  majority  of  cases  the 
urethra  should  remain  under  observation  for  at  least  a  year  and 


STRICTURE  OF  THE  URETHRA  353 

explored  with  boiif^ics-a-boulc,  sounds  anr]  the  urethroscope  for  any 
tendency  toward  recontraetion,  which  should  be  dealt  with  according 
to  indication.  The  interval  of  passing  instruments  in  prevention  of 
relapse  is  a  matter  of  study  and  experience  in  each  case  and  of  behavior 
of  the  stricture.  Observation  of  shreds  and  other  signs  of  urethritis 
at  and  about  the  site  of  the  former  stricture  is  a  most  important  detail 
in  foretelling  the  outlook  of  the  case. 

Diagnosis.^ — The  recognition  of  stricture  depends  on  the  four  factors 
of  history,  physical  examination,  laboratory  analysis  and  treatment. 
The  last  concerns  more  the  matter  of  relapse.  In  the  history  we  have 
the  causal  factors  of  trauma,  operation,  long  repeated  and  relapsing 
urethritis  and  pressure  by  the  prostate  and  neoplasm,  and  occasionally 
the  detail  of  nervous  irritability  in  spasmodic  examples.  The  diagnosis 
of  diatheses  is  important  on  account  of  their  relation  with  urethritis, 
associated  with  stricture.  The  subjective  symptomatology  belongs  to 
the  history  and  reveals  discharge,  pain,  frequency,  tenesmus,  sense  of 
obstruction,  altered  stream  and  urine,  sexual  disorder  and  sexual  or 
urinary  complications.  The  physical  examination  should  include  the 
general  constitution  of  the  patient,  as  just  stated,  and  the  external  and 
internal  urethral  examination,  embracing  also  rectal  touch.  External 
palpation  usually  reveals  but  little,  but  examination  within  the  urethra 
with  bougies,  sounds,  urethroscopes,  filiform  guides,  catheters  and  the 
like  is  of  preeminent  importance  and  should  never  be  omitted.  A 
preliminary  meatotomy  is  often  necessary  for  suitable  diagnosis  and 
treatment  as  through  the  urethra  stenosed  by  a  small  meatus  very 
little  can  be  accomplished.  The  points  to  be  recognized  are  the 
diameter  of  the  stricture,  the  distance  from  the  meatus,  extent,  number, 
condition  of  the  proximal  mucosa,  congestion,  irritability  and  resihency 
of  the  band.  Many  stricture  cases  suffer  from  toxemia  and  absorption, 
so  that  slight  instrumentation  induces  urethral  chill.  This  may  often 
be  aborted  by  the  administration  of  a  pill  containing  morphine,  grains 
I  to  \,  fluidextract  of  aconite,  minims  1  to  2,  and  quinine,  grains  5. 
Usually  one  of  these  pills  in  dose,  according  to  the  patient's  constitu- 
tion, given  in  the  forepart  of  the  examination,  will  abort  the  chill.  Irri- 
gation of  the  urethra  with  mild  antiseptics  and  the  administration  of 
urinary  antiseptics  internally  are  other  cautions.  Patients  should  be 
warned  as  to  the  ardor  urinse  which  follows  exploration  arid  aided  by 
the  administration  of  alkalies,  blenorrhetics  and  urinary  antiseptics. 

The  bacteriology  and  infectiousness  of  a  stricture  are  sjTiomTnous 
and  are  very  important  because  instrumental  invasion  of  the  region 
may  be  followed  by  direct  transference  of  organisms  mto  the  urinary 
organs.  Such  accident  is,  however,  commonly  avoided  by  the  foregoing 
precautions.  A  more  serious  condition  which  cannot  be  so  readily 
avoided  is  direct  absorption  of  the  gonococci  and  other  organisms  into 
the  blood  current  through  mmute  w^omids  of  the  mucosa  essential  and 
unavoidable  during  the  exploration.    The  MTiter  recalls  a  case  in  which 

1  Pedersen,  V.  C:  Arch.   Diag.,    October,  1910. 
23 


354     COMPLICATIONS  AND  SEQUELS  OF  CHRONIC  URETHRITIS 

polyarthritis  of  botli  Icnees,  one  slioiikler,  both  elbows  and  one  ankle, 
as  well  as  probably  a  myositis,  followed  the  soundino;  of  a  stricture 


Fig.  93. — Exploration  of  a  stricture  with  a  sound.  The  left  hand  gently  presses 
the  sound  against  the  stricture,  wliile  the  right  hand  upon  the  perineum  or  in  the  rectum 
locates  and  studies  the  stricture.     (Original.) 


i 

y^ 

%flK^ 

Fig.  94. — Exploration  of  a  stricture  with  the  bougie-il-boule.  The  left  hand  supports 
the  bougie  against  the  face  of  the  stricture  and  holds  the  urethra  gently  on  the  stretch. 
The  right  hand  locates  the  instrument  and  examines  the  stricture  beyond  it.     (Original.) 


STRICTURE  OF  THE  JJRETIJRA 


355 


within  a  few  hours,  in  which  no  })acterio]of^ic  knowledge  of  the  case 
had  previously  been  secured.  'J'he  details  of  such  bacterioloj^ic  investi- 
gation need  not  be  repeated  more  than  to  say  that  they  include  smear 
and  culture  of  shreds,  centrifugiiig  the  urine  and  again  making  smears 
and  cultures  and  finally  the  complement  fixation  test  of  .Schwartz. 
Such  an  investigation  puts  us  at  once  in  control  of  this  im})ortant  part 
of  the  case. 


Fig.  95. — Palpation  for  stricture  with  the  bougie-a-boule.  The  penis  is  supported 
in  the  left  hand  in  the  vertical  position  and  the  instrument  is  gently  passed  along  the 
canal  until  the  obstruction  is  felt.  The  index  finger  and  thumb  of  the  right  hand  now 
seize  it  at  the  meatus  for  withdrawal  and  for  marking  the  distance  of  the  node  from  the 
outlet.     (Original.) 

The  diameter  of  the  stricture  is  measured  by  passing  flexible  bougies- 
a-boules,  beginning  with  the  largest  which  will  pass  the  meatus,  thus 
reaching  the  anterior  limits  of  the  infiltration  and  perhaps  showing 
strictures  of  larger  caliber  m  front  of  it  previously  unsuspected.  The 
same  instrument  may  be  used  to  measure  the  distance  from  the  meatus 
of  each  such  stricture.  Finally,  a  bougie-a-boule  is  secm-ed  which 
passes  through  the  narrowing  and  then,  as  it  is  withdrawn,  its  point 
of  engagement  on  the  posterior  surface  of  the  narrowing  is  noted  and 
measured  and  the  difference  between  this  measurement  and  that  of 


35G    COMPLICATIOXS  AXD  SEQUELS  OF  CHRONIC  URETHRITIS 

the  face  of  the  lesion  from  the  meatus  indicates  the  extent  of  the 
stricture  along  the  canal.  If  no  bougie-a-l)oule  will  ])ass  the  stricture, 
then  the  whalebone  Hlit'orin  guide  becomes  available  and  the  extent 
must  rest  du  external  and  rectal  i)alpation  of  the  urethra.  By  these 
steps  not  only  are  the  number  of  stenoses  developed,  but  with  gentleness 
the  condition  of  the  mucosa  about  them  may  be  suggested.  The  ure- 
thritis almost  universal  above  a  stricture  is  easily  jM-ovokcd  into  bleed- 
ing and  irritabilitx .  Should  such  symi)toms  arise  during  a  cautious 
and  gentle  examination,  the  conclusion  that  the  mucosa  is  diseased  is 
reasonable  and  proper,  although  not  final.  The  latter  point  is  reached 
only  by  urethroscopic  examination  of  the  entire  mucosa  when  the 
instrument  ma>-  be  ])assed  through  the  stricture  or  of  the  distal  mem- 
l)rane  when  only  its  face  may  be  reached.  The  dilating  urethrometers, 
of  which  the  Otis  is  the  best  type,  may  be  used  for  some  of  these  func- 
tions, in  that  the  shaft  of  the  instrument  collapsed  will  pass  rather 
small  strictures.  It  is  of  15  Fr.  diameter  closed  and  45  Fr.  diameter 
when  extended.  The  natural  elasticity  of  the  urethra  both  in  health 
and,  in  many  mstances,  in  disease  and  the  tendency  of  pouch-formation 
proximal  to  strictures  both  make  the  accuracy  of  this  instrument 
vmcertain,  because  the  power  exerted  by  its  screw  is  so  great,  through 
no  faidt  in  its  design,  that  the  resistance  of  the  canal  is  not  trans- 
mitted to  the  operator  with  sufficient  definiteness  for  mensuration. 
It  is  for  this  reason  that  the  writer  considers  this  type  of  instrument 
not  an  essential  part  of  the  urologist's  armamentarium. 

The  elasticity  of  the  stricture  is  suggested  only  by  noting  whether 
closure  of  the  canal  to  its  original  diameter  slowly  or  quickly  follows 
the  use  of  exploring  mstruments  of  known  caliber. 

Laboratory  analysis  of  shreds  and  discharge  associated  with  stricture 
and  obtained  from  the  urine  or  through  a  urethrosco])e  reveals  the 
gonococcus  on  smear  and  culture  with  its  allies  and  l)r()^•es  the  safety 
or  danger  of.  treatment.  The  gonococcal  complement  fixation  test, 
if  positive,  demonstrates  absorption  from  the  lesion  and  treatment 
through  the  various  methods — such  as  dilatation  and  internal  or 
external  uretlirotomy — is  often  the  finality  of  the  anatomical  diagnosis. 

Differential  Diagnosis. — The  difi'erential  diagnosis  is  interested  in  dis- 
tinguishing gonococcal  organic  stricture  from  the  various  other  forms, 
especially  stricture  by  trauma,  spasm  and  extraurethral  ])ressure. 

Inflammatory  differs  from  gonococcal  stricture  in  the  history  of  a  very 
acute  infection  which  duplicates  the  gonococcal  invasion  in  its  severity 
and  sudden  onset;  in  its  subjective  symptoms  of  inability  to  urinate, 
and  excessi\e  pain  due  to  inflammation  of  the  urethra  and  distention 
of  the  bladder;  in  its  objective  findings  of  great  edema  and  swelling 
of  the  urethra  as  a  whole  and  especially  on  rectal  examination,  and  of 
the  distended  l)ladder  by  i)al])ation  and  ])ercussioii  abox'c  the  sym})hysis 
in  its  laboratory  determination  of  the  offending  organism  with  absent 
gonococcal  fixation  test;  and  in  its  rather  ready  relief  by  rest,  sitting 
baths,  decongestants,  sedatives,  penile  baths  and  hot  packs  with  the 
absence  of  organic  fibrosis  on  exploration  after  all  symptoms  have 


STRICTURE  OF  THE  URETHRA  357 

subsided  and  cure  is  established.  It  should  be  remembered  that  intense 
gonococcal  infection  may  produce  this  form  of  stricture— strifrture  by 
edema — which  must  then  be  distinguished  from  the  organic  type  by 
this  last  test,  that  is,  exploration  after  cure  is  otherwise  established. 

Spasmodic  differs  from  gonococcal  stricture  in  the  admission  of  urethral 
exploration  and  of  nervous  defects  of  the  patient  toward  any  medical 
or  surgical  examination;  in  its  subjective  symptoms  of  inability  to 
urinate  even  after  great  strain  and  objective  absence  of  nodes  of  the 
urethra  externally  by  palpation  or  internally  by  instrumental  investi- 
gation with  presence  of  obvious  muscular  spasm  perceived  through 
the  rectum  along  the  compressor  urethne  muscle;  in  its  laboratory 
findings  of  present  or  absent  inflammation  or  infection  in  agreement 
with  the  incidence  of  these  lesions  as  the  sources  of  the  spasm  rather 
than  mere  instrumental  reflex  irritation  and  accordingly  with  the 
absence  of  the  gonococcus  and  the  complement  fixation  test  and  in  its 
ready  relief  by  simple  treatment  with  rest  in  bed,  hot  baths,  anti- 
spasmodics and  temporary  cessation  of  instrumentation,  whose  later 
success  proves  the  absence  of  organic  stricture. 

Periurethral  pressure  differs  from  gonococcal  stricture  in  the  history  of 
growth  associated  with  urethra,  prostate  or  rectum;  in  its  subjective 
symptoms  of  slow  onset  in  chronic  conditions,  such  as  neoplasms,  or  of 
rapid  appearance  during  acute  lesions,  such  as  extravasation  of  urine 
or  hematoma;  in  the  objective  presence  of  the  new  grow^th  or  accumu- 
lation of  urine  or  blood  with  the  obstruction,  but  absence  of  discharge 
from  the  urethra;  in  its  discovery  of  the  contents  of  the  mass  as  solid 
or  fluid,  bloo  d  or  pus,  by  aspiration ,  in  the  laboratory  development  of 
no  infection,  no  urethral  pus  and  no  blood  unless  abscess  is  present  or  a 
neoplasm  has  ulcerated  into  the  canal,  and  of  proof  of  no  gonococci  on 
smear  or  culture  or  no  positive  complement  fixation  test  and  in  the 
final  anatomical  diagnosis  by  removal  of  the  growth  in  whole  or  part 
and  evacuation  of  the  fluid  by  incision  and  drainage,  of  which  both 
may  be  followed  by  a  pathologist's  examination. 

Traumatic  differs  from  gonococcal  stricture  in  its  history  of  recent  or 
old  injury  with  obvious  and  characteristic  conditions  arising  therefrom ; 
in  its  symptoms  of  intense  severe  sudden  onset  in  recent  traiuna  or  of 
slower  though  intense  establishment  in  remote  injuiies,  with  the  objec- 
tive signs  of  the  injury  in  new  cases  or  of  dense  scar,  extraurethral  or 
intraurethral,  in  old  cases ;  in  its  laboratory  findings  of  little  or  no  pus, 
no  gonococci  or  other  pathogenic  organisms,  on  smear  or  cultm'e  and 
no  complement  fixation  test;  in  its  demonstration  in  the  treatment  of  a 
dense  scar  extending  into  the  annexa  in  old  cases  and  of  obvious  lacera- 
tions of  the  part  in  recent  forms. 


CHAPTER   VII. 

TREATMENT  OE   STRKTERE   OE  'VUl]  rRETIIUA.    URE- 
THRAL INEECTIOXS  L\'  CTHLDHOOL)  AND  OLD  AGE. 
COMPLICATIONS  OF  STRICTURE. 

Significance. — Stricture  is  one  of  the  most  ini])ortant  lU'ological  con- 
ditions and  requires  jud<;nient  and  care  for  results.  Its  treatment  may 
be  considered  imder  the  usual  headings  of  preparation,  prevention, 
management,  alleviation,  cure  by  nonoperative  and  operative  meas- 
nres,  aftertreatnuMit  an<l  accidents  of  treatment. 

Preparation  of  the  Patient. — Except  emeri>encies  and  the  held  itself, 
which  nuist  be  dealt  with  according  to  well-known  principles,  the  pvvp- 
aration  is  both  systemic  and  local.  The  general  measures  include  light 
diet,  no  alcohol  or  other  stimulants  in  order  to  keep  the  renal  fimction 
at  rest,  and  directions  to  the  patient  for  securing  quiet,  both  bodily  and 
ssxual,  during  the  treatment,  and  arrangements  for  confinement  to 
bed  in  the  more  severe  and  operative  conditions,  l^rinary  antiseptics 
should  be  administered  for  several  days  previously  in  order  to  render 
the  urine  bland  and  safe,  and  to  flush  out  the  urethra  with  urine  charged 
with  antiseptics.  The  local  preparation  involves  the  ai)plication  of 
decongestants  like  adrenalin,  weaker  antiseptics  like  2  or  4  per  cent. 
boric  acid  water,  or  1  in  3000  nitrate  of  silver,  astringents  of  which 
none  is  better  than  silver  nitrate  and  hot  penile  sitting  and  body  baths, 
which  act  both  locally  on  the  urethra  and  generally  on  the  skin  to  the 
relief  of  the  kidneys. 

Prevention. — It  is  necessary-  to  include  instruction  of  the  patient  and 
measures  to  limit  the  penetration  of  the  urethritis  as  far  as  possible. 
The  patient  should  have  instruction  by  reprints,  other  pamphlets  or 
printed  circulars  setting  forth  the  importance  of  chronic  urethritis 
and  the  tendency  and  significance  of  stricture. 

Instructions  on  Chronic  Gonorrhea  and  Stricture. 

Chronic  Gonorrhea. — Chronic  gonorrhea  is  the  imcured  final  stage  of 
the  acute  gonorrhea.  Jt  is  also  known  under  the  terms  of  gleet,  chronic 
urethritis,  clap,  chronic  drip  or  dri])])ings,  etc.  All  these  words  mean 
the  one  an<^l  same  disease. 

Chronic  gonorrhea  means  that  somewhere  in  the  urinary  canal  severe 
damage  has  occurred  to  the  lining  or  mucous  membrane,  to  few  or 
many  of  the  minute  glands  which  furnish  the  moisture  of  the  mucous 
membrane,  or  even  to  such  important  parts  of  the  sexual  apparatus 
as  the  prostate  gland.  Any  one,  any  two,  or  all  three  of  these  condi- 
tions may  be  present.    This  constitutes  chronic  gonorrhea  and  is  one 


INSTRUCTIONS  ON  CHRONIC  GONORRHEA  AND  STRICTURE        359 

of  the  most  important  venereal  diseases  because  unless  cured  it  leads 
to  progressive  conditions,  especially  stricture,  as  briefly  explained  on 
page  2(56. 

Chronic  gonorrhea  is  also  the  source  of  infection  of  many  innocent 
persons  of  the  opposite  sex  in  marriage.  Infection  of  women  in  this 
way  accounts  for  fully  50  per  cent,  of  all  operations  for  abscesses  of 
the  ovaries. 

The  most  constant  symptom  of  chronic  gonorrhea  is  a  slight  drop 
varying  in  amount, and  frequency  and  in  color  from  yellow  to  whitish. 
It  is  most  abundant  in  the  morning  upon  arising.  Sometimes  there 
is  also  a  sense  of  discomfort  in  the  canal.  This  drop  washes  away  with 
the  urine  and  largely  accounts  for  the  so-called  "floaters,"  "shreds," 
and  "threads"  in  the  urine. 

Stricture. — Stricture  of  the  urethra  is  any  obstruction  of  the  size  of 
the  urinary  canal,  open  or  close  in  degree.  Stricture  is  also  any  change 
in  the  natural  form  or  course  of  the  urinary  canal,  great  or  small. 
Strictiue  is  caused  by  injury  or  disease,  and  necessarily  includes  a 
permanent  lifelong  change  in  the  lining  or  mucous  membrane  of  the 
canal  and  of  the  structures  just  outside  the  canal.  In  other  words, 
stricture  is  a  callous  spot  or  permanent  scar  of  previous  injury  or 
disease  in  the  canal. 

The  danger  of  strictm'c  is  that  it  makes  a  backset  against  the  flow  of 
urine,  like  a  dam  in  a  stream,  which  is  felt  by  the  urinary  passage,  then 
by  the  bladder,  next  by  the  tubes  leading  from  the  kidneys  to  the 
bladder,  called  the  ureters,  and  finally  in  severe  cases  by  the  kidneys 
themselves.  It  is  not  necessary  for  the  urine  to  be  entirely  shut  off  in 
order  to  make  a  strictiu-e  a  very  dangerous  condition.  Stricture  gives 
about  the  same  symptoms  as  chronic  gonorrhea,  combined  with  at 
first  slight  then  great  changes  in  the  size  and  form  of  the  urinary  stream. 
A  most  careful  examination  should  always  be  made  of  the  stricture, 
and  if  one  is  present  even  in  moderate  degree  gentle  treatment  of  it 
is  necessary.  Nature  never  intended  the  urinary  apparatus  to  work 
against  the  disadvantage  of  obstruction  along  the  course  of  the  stream 
of  urine. 

Treatment  of  Stricture. — Most  strictures  may  be  stretched  open  until 
the  passageway  is  restored  to  its  natural  form  and  size,  but  since 
strictures  are  only  scars,  their  tendency  is  to  cause  fresh  diflSculty 
unless  they  are  watched.  Therefore  it  is  necessary  to  pass  an  instru- 
ment tlirough  the  passageway  three  or  foiu"  times  a  year  throughout 
life  in  order  to  prevent  a  retiu-n  of  the  strictm-e. 

Educational  measures  include  a  circular  employed  in  the  writer's 
clinic  with  very  great  advantage.  The  most  important  direction  for 
the  patient  is  strict  obedience  to  orders  and  abstmence  from  self- 
treatment  which  almost  always  involves  hand  injections  of  too  great 
concentration  and  too  frequent  use.  A  safe  rule  is  that  no  hand 
injection  or  application  should  be  used  whose  ardor  and  astringency 
persists  more  than  a  few  moments  and  that  without  definite  spasm 
or  other  disturbance  of  the  bladder.    Almost  every  iu*ethritis  during 


360  TREATMEXT  OF  STRICrURE  OF  THE  URETHRA 

the  first  month  after ivoovcry  will  loa\c  hehiiul  it  soft  infiltrat»ions  which 
usually  disappear  if  left  alone.  They  almost  always  beeome  fibrous 
if  sounds  are  passed  prematm-ely,  roughly,  or  of  too  large  diameter. 
Thus  an  important  element  in  the  ])re^•ention  of  stricture  is  conserva- 
tism in  the  use  of  instruments  with  relation  to  con^■aleseence,  size  and 
method  of  enii)loymeut.  Again,  another  factor  in  pre\-ention  is  the 
patient's  own  conduct  in  the  avoidance  of  sexual,  dietetic  and  alcoholic 
excess,  diu-ing  any  part  of  the  urethritis,  which  will  always  augment 
existing  conditions  and  freciuently  induce  new  manifestations. 

jManagenient  during  the  treatment  distinguishes  the  o])erative  and 
the  nonoperati\e  cases.  Chapter  IX,  on  (leneral  Principles  of  Treat- 
ment, supplies  the  requisite  data  of  this  subject  in  every  detail. 

The  management  of  operative  cases  varies  with  the  form  of  opera- 
tion and  therefore  will  be  described  as  an  essential  of  the  technic  of 
each  operation  in  subsequent  pages. 

The  operative  cases  should  all  be  in  bed  until  the  wound  is  w^ell 
granulating,  and  during  this  period  they  should  receive  the  usual  niu's- 
ing,  diet  and  medication  for  urological  conditions,  with  special  reference 
to  the  condition  of  the  kidneys.  If  these  are  aft'ected  at  all  the  rest  in 
bed,  the  quiet  of  the  urinary  canal  through  relief  of  the  obstruction 
and  drainage,  suitable  urinary  antiseptics,  sedatives  and  diuretics  and 
dietetics  will  accomplish  marvels  in  many  cases.  The  author  has  found 
the  following  simple  formuh^  of  service. 

As  antiseptics: 

I^ — Hcxamethylonamin gramme  0.3  (grains  5) 

Salicylate  of  soda         gramme  0.3  (grains  5) 

Distilled  water gramme  0 .  06         (dram    1) 

Mix  and  mark: 
Dram  1,  in  a  glass  of  water,  everj^  two  to  four  hours. 

Or  combined  with  salicylate  of  soda  in  the  foregoing  formula,  acid 
phosphate  of  soda  may  be  used  in  equal  or  double  quantities. 

This  formula  is  of  special  value  in  the  colon  bacillus  infections  of  the 
kidney  and  bladder,  and  its  dose  may  be  increased  temporarily  as 
desired.  Instead  of  the  formin,  other  formaldehyde  preparations  may 
be  employed.  Urinah'sis  should  be  periodically  made  during  the 
administration  of  such  formaldehyde  drugs  because  this  chemical 
may  irritate  the  kidneys  profoundly,  producing  bleeding  and  casts, 
and  should  then  be  discontinued.  In  such  an  event  the  older  urinary 
antiseptics  should  be  tried. 

As  sedatives: 

^ — Acetate  of  potash grammes  1 .  20         (grains    20) 

Tincture  of  hyoscyamus gramme    1 .  00         (minims  15) 

Distilled  water up  to  grammes  4 .  00         (dram        1) 

MLx  and  mark; 
Dram  1  or  2  in  a  glassful  of  water  every  two  to  four  hours. 

IJ — Fluidextract  of  triticum  repens, 

Fluidextract  of  uva  ursi      .      .      .  of  each  grammes    46.50       (ounces  1^) 

Liquor  of  potash grammes    15.50       (ounce      \) 

Distilled  water up  to  grammes    124.00       (ounces  4) 

Mix  and  mark: 
Dram  1,  in  water,  two  hours  after  eating  and  during  the  night. 


INSTRUCTIONS  ON  CHRONIC  GONORRHEA  AND  STRICTURE     3G1 

Both  these  formulas  are  diuretics  and  antacids,  uciitraHzers  and 
alkalizers  according  to  the  amount  administered. 

The  bicarbonate  of  soda  grains  5  to  liO  from  three  to  six  times  a  day 
may  act  in  the  same  manner. 

As  diuretics : 

I^ — Acetate  of  potash gramme    1 .  00         (grains  15) 

Distilled  water up  to  grammes  4.00  (dram      1) 

Mix  and  mark: 
Dram  1  or  2,  in  water,  every  two  to  four  hours,   or  three  times  a  day   two   hours 
after  eating. 

I^ — Citrate  of  potash gramme    1.00  (grains  15) 

Syrup  of  lemon grammes  2 .  00      (fluidram    ^) 

Distilled  water up  to  grammes  4 .  00     (fluidram    1) 

Mix  and  mark: 
Drams  1  or  2,  in  a  glassful  of  water,  every  two  to  four  hours. 


Simple  lemonade  and  the  judicious  drinking  of  plain  or  medicinal 
waters  are  also  good  diuretics.  Among  the  latter  the  best  are  French 
Vichy  and  Swannee  Water.  "Imperial  drink,"  consisting  of  cream  of 
tartar,  ounce  1,  lemon  juice  and  water  up  to  a  pint  is  also  a  good 
diuretic. 

The  dietetics  of  all  these  operations  is  the  standard  for  other  surgical 
interference,  combined  with  that  specially  adapted  for  nephritis,  and 
need  not  be  here  discussed. 

The  management  of  the  nonoperative  cases,  that  is  to  say,  of  the 
patients  under  dilatation,  requires  in  general  much  the  same  details 
as  for  subacute  urethritis,  because  the  regular  instrumentation  of  the 
canal,  at  least  at  first,  until  the  lumen  of  the  infiltration  has  been 
advanced  sufficiently  for  good  drainage,  is  very  apt  to  provoke  a  mild 
subacute  reaction.  The  patients  are,  therefore,  put  on  a  mild  non- 
irritating  diet,  urinary  antiseptics,  blennorrhetics,  and  occasionally 
hand  injections.  If  the  stricture  is  quite  tight  they  are  sent  home  to 
bed  or  quiet  for  the  rest  of  the  day,  a  step  which  makes  the  evening 
office  hour  the  best  for  such  treatment  because  the  patient  may  then 
return  home  for  a  light  supper  and  a  long  night's  rest,  preferably  after 
a  hot  sitting  bath,  which  often  tends  to  prevent  stricture  by  edema  for  a 
short  time  after  the  dilatation.  Such  a  sitting  bath  may  be  conveniently 
taken  in  an  ordinary  tub  if  the  patient  has  no  special  sit-bath  fixture, 
by  drawing  about  twelve  inches  of  hot  water  into  the  standard  tub,  in 
which  the  patient  sits  with  his  lower  extremities  extended  and  the 
water  up  to  his  navel.  The  heat  of  the  water  should  be  sufficient  to 
leave  the  skin  distinctly  congested  in  a  high  pmk  color  and  the  bath 
should  be  continued  for  about  twenty  minutes,  after  which  he  retires  at 
once  to  bed. 

The  diet,  antiseptics,  and  blennorrhetics  have  been  sufficiently 
described  in  pages  67  and  68  and  need  no  addendum  here,  a  hand 
injection,  rarely  needed  if  gentleness  and  deliberation  in  the  dilatation 


362  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

are  followed,  had  best  be  of  the  astrini:;ent  type,  and  none  is  better 
than  the  full  or  half-strength  Ultzniann  injeetion: 

I^ — Zinc  sulphate grains  6  to  12 

Lead  acetate grains   6  to  12 

Distilled  water up  to  ounces  G 

Mix  and  mark: 
Inject  carefully  as  directed  from  two  to  four  times  daily. 

The  directions  for  hand  injections  for  the  patient  are  advisedly 
set  down  in  a  printed  circular  which  is  given  on  page  5(),  under 
the  treatment  of  gonococcal  acute  urethritis.  In  stricture  cases  the 
sit-bath  and  the  irrigation  of  the  urethra  by  the  urologist  directly 
after  the  passing  of  the  sound  with  hot  normal  salt  solutions,  1  in  5000 
adrenalin  solution,  2  to  4  per  cent,  boric  acid  water,  ])otassiiini  per- 
manganate solution,  1  in  10,000  to  1  in  4000,  argyrol  5  ])er  cent.,  pro- 
targol  1  per  cent.,  all  with  a  temperature  of  105°  to  120°  F.,  according 
to  tolerance,  will  itself  reduce  the  likelihood  of  edema  and  temporary' 
closure  of  the  canal;  but  most  important  are  the  gentleness  of  manipu- 
lation and  the  infrequency  of  treatment  as  hereinafter  detailed.  The 
special  catheter  sounds  of  the  author,  permitting  filling  of  the  bladder 
with  irrigation  and  the  flushing  of  the  urethra  by  the  patient  himself, 
are  here  serviceable. 

The  aIle^■iation  treatment  is  largely  the  effort  to  control  the  urethritis 
and  other  accom])anunents  of  stricture  or  its  complications.  All  the 
foregoing  formulas  have  their  function  in  this  field  and  must  be  applied 
in  accordance  with  the  condition  predominating. 

The  curative  treatment  is  subdi\isible  into  nonoperati\"e  anfl  opera- 
tive measures,  a  distinction  which  rests  solely  on  the  administration 
of  anesthetics  and  a  distinctly  cutting  operation  instead  of  dilatation 
of  the  canal  with  various  means — a  process,  however,  wdiich  should 
command  respect  fully  as  much  as  the  more  directly  operative  pro- 
cedures. 

Immediate  Indications  of  Treatment  are  to  relie^•e  the  closure,  deform- 
ity and  inflammation  of  the  urethra,  to  evacuate  the  retention  of  urine, 
even  though  partial,  to  remove  the  back-pressure  or  tendency  thereto, 
to  heal  the  diseased  mucosa  wherever  involved  in  the  urethra,  bladder 
or  upper  urinary  organs,  to  prevent  and  cure  any  of  the  severe  compli- 
cations, and  finally  to  reach  the  cause  of  the  stricture  when  possible. 
The  remote  indications  are  to  prevent  relapse  of  the  stricture  itself, 
its  effects  and  complications.  The  application  of  the  various  methods 
of  treatment  to  these  aims  will  be  sufficiently  obvious  in  the  description 
of  the  various  procedures. 

Methods  of  Treatment  are  as  stated  nonoperative  and  operative,  in 
each  of  which  several  have  been  approved  and  disapproved.  The 
approved  nonoperative  methods  are:  (1)  gradual  dilatation,  (2)  con- 
tinuous dilatation  and  (3)  electrolysis,  and  the  recognized  operative 
measures  are:  (1)  dilating  urethrotomy,  (2)  internal  urethrotomy,  (3) 
combined  external  and  internal  urethrotomy  and  (4)  excision.  The 
disapproved  nonoperative  steps  are:  (1)  caustics  and  (2)  divulsion,  and 


INSTRUCTIONS  ON  CHRONIC  GONORRHEA  AND  STRICTURE        303 

the  obsolete  operative  procedures  are:  (1)  for^uhlc  diliitiiiK  nrctlirotorny 
and  (2)  subcutaneous  section. 

Disapproved  Nonoperative  Methods. — All  the  caustics  an;  und(;r  abso- 
hite  condemnation  because  they  replace  the  ordinary  inflarrnnatory 
deposit  constituting  the  stricture  and  often  not  hbrous  with  a  cliernical 
traumatic  cicatrix  which  is  always  fibrous  and  among  the  most  difficult 
infiltrations  to  treat  in  that  it  extends  beyond  the  mucosa  into  the 
corpus  spongiosum  and  the  periurethral  planes.  Caustic  potash  seems 
in  the  past  to  have  been  commonly  employed  by  various  special  instru- 
ments called  portes  caustiques  or  caustic  porters.  Divulsion  is  also 
obsolete  in  that  it  is  a  coarse  traumatism,  very  irregular  in  action, 
uncontrolled  in  limits  and  disrespects  the  possibilities  of  infection 
and  septic  absorption.  It  consists  in  passing  a  dilating  instrument 
through  the  stricture  and,  at  one  sitting,  with  or  without  local  or 
general  anesthetics,  opening  the  blades  and  restoring  the  caliber  of  the 
canal.    The  foregoing  objections  to  it  are  at  once  manifest. 

Disapproved  Operative  Methods. — A  procedure  on  the  border  line 
between  the  proper  and  the  improper  types  is  dilating  urethrotomy, 
which  is  a  combination  between  divulsion  and  internal  urethrotomy. 
It  is  the  former  element  of  undue  dilatation  which  is  the  disapproved 
feature  on  the  same  grounds  as  divulsion  itself.  If,  however,  this 
particular  step  is  limited  to  ordinary  tension  of  the  stricture  upon  the 
shaft  of  the  urethrotome,  then  the  operation  is  really  modern  internal 
urethrotomy,  and  is  by  no  means  unfavorably  regarded,  and  its  details 
are  discussed  on  pages  390  to  395.  Subcutaneous  section  by  which  effort 
is  made  to  divide  the  ofi^ending  band  by  a  more  or  less  stabbing  opera- 
tion through  the  skin  is  also  an  unguided  and  condemned  operation 
without  advantageous  feature. 

With  this  dismissal  of  the  improper  methods  of  treating  stricture, 
the  application  of  the  approved  technics  will  be  shown  with  relation 
first  to  their  own  indications  and  second  to  the  various  types  of  stric- 
ture and  their  complications. 

Comparison  of  Dilatation  and  Operation. — In  general,  indications  show 
that  it  is  a  good  rule  to  make  reasonable  effort  to  dilate  all  strictm'es.' 
Exceptions  to  this  rule  are:  (1)  when  drainage  is  indicated  as  a  means 
of  benefiting  the  posterior  urethra  and  bladder;  (2)  often  when  the 
stricture  is  smaller  than  7  Fr.  in  caliber,  because  most  of  this  class  of 
cases  are  complicated  and  benefited  by  open  operation;  (3)  when  a 
stricture  is  highly  elastic  and  does  not  remain  dilated  and  (4)  when 
complications  coexist  with  the  strictiu"e.  The  following  other  general 
principles  as  to  choice  between  dilatation  and  operation  are  applicable 
and  explicable: 

1.  Gradual  dilatation  is  the  preferred  method  m  all  succulent, 
dilatable,  elastic  newly  acquired  strictiu-e.  Diameter  of  lumen  and 
position  of  the  stricture  in  the  canal  do  not  affect  this  rule.  The  impor- 
tant point  is  the  recency  of  the  stricture.  If  intervention  with  newly 
formed  infiltrations  is  begun  too  soon,  they  will  be  stimulated  to  form  a 

1  Pedersen,  V.  C:  Jour.  Am.  Med.  Assn.,  January,  1910,  and  Am.  Jour.  Urol.,  March, 
1910. 


304  TREATMlEXT  OF  STRICTrRE  OF  THE  URETHRA 

trauinatlc  stricture,  whose  eliaraeter  will  \ary  aeeordiiiii;  to  the  nature, 
fre(iuency  and  violenee  of  the  treatment  and  the  reaction  of  the 
])atient"s  tissues  in  such  cases. 

2.  Continuous  dilatation  is  ad\  isablc  in  tiuht  stricture  without 
irritability  or  complications,  permittino;  only  a  filiform  to  penetrate 
them.  One  or  two  filiforms  are  left  ///  ffitii  for  twenty-four  or  forty- 
eight  hoiu's,  during  which  they  will  by  expanding  under  the  moisture 
of  the  canal  dilate  it  to  7,  8  or  9  Fr.,  after  which  the  tunnele<l  an<l 
grooved  irrigating  sounds  of  the  writer  may  be  employeil.  If  the 
bacteriology  of  the  stricture  shows  infection,  or  its  behavior  irritability, 
this  ])lan  cannot  be  ado])ted.  If,  at  the  end  of  forty-eight  hours,  no 
yielding  has  occurred  so  that  an  instrument  nuiy  be  threaded  over  the 
filiform,  continuous  dilatation  had  best  be  abandoned,  otherwise  infec- 
tion of  the  bladder  and  even  ulceration  may  super\ene  by  pressm-e 
effects  of  the  coiled  filiform  upon  the  mucosa. 

:].  Electrolysis  is  often  regarded  as  a  disa])i)roved  method,  but  in 
the  hands  of  experts  with  suitable  apparatus  it  should  be  regarded  as 
one  of  the  accepted  methods,  in  that  its  softening  and  relaxing  actions 
are  of  great  ad\'antage  in  selected  cases.  A  great  difficulty  is  that 
electrolysis  by  modern  methods  requires  expensive  and  somewhat 
ciunbersome  aj^paratus  in  order  to  provide  the  \ariety,  range  and  con- 
trol of  the  currents.  It  cannot  be  proper!}-  applied  by  small  and  cheap 
apparatus,  which  might  be  designated  as  electrical  or  scientific  toys. 
On  the  other  hand,  electrolysis  is  not  to  be  regarded  as  a  kind  of  ciu'e-all 
method,  but  as  a  method  with  distinct  limitations. 

(4)  Internal  urethrotomy  will  relieve  all  cicatricial,  irritable,  highly 
elastic  strictures  in  the  anterior  m'ethra,  including  the  bulbous  urethra, 
and  is  applied  along  the  roof,  excepting  at  the  meatus  where  the 
incision  is  only  along  the  floor.  Dilatation  fails  in  stricture  of  the 
meatus,  so  that  meatotomy  alone  will  relieve  an  infiltration  causing 
symptoms.  Before  internal  urethrotomy  is  ever  attempted  except 
in  emergencies,  a  bacteriologic  examination  should  be  made  of  pus 
present.  If  vicious  germs  are  found,  local  treatment  should  be 
attempted  for  their  destruction,  if  i)ossible,  before  any  operation 
whatever  is  practicable. 

5.  External  perineal  uretlirotomy  with  a  guide  or  perineal  section 
with  a  guide  is  available  for  all  cicatricial,  irritable,  highly  elastic, 
infected  or  complicated  strictures  of  the  i)osterior  urethra,  whether 
in  the  membranous  or  prostatic  portions.  One  of  the  greatest  indica- 
tions of  external  urethrotomy  is  the  presence  of  pus  which  would  be 
benefited  by  the  drainage  of  this  operation  and  the  same  basic  principle 
applies  to  the  following  paragraph. 

(J.  Combined  internal  and  external  urethrotomy  is  indicated  for 
dense  cicatricial  strictures  of  the  anterior  urethra  with  such  complica- 
tions as  fistula  and  false  passage,  inasmuch  as  the  drainage  of  the  peri- 
neal tube  permits  the  complication  to  be  treated  surgically  or  otherwise. 

7.  External  perineal  urethrotomy  without  a  guide,  or  perineal 
section  without  a  guide  will  relieve  the  deep  impassable  strictures. 
Urethral  injection  of  dye-stuffs,  such  as  indigo  carmine,  will  often  map 


NONOPERATIVE  TREATMENT  OF  STRICTURE  305 

out  the  tortuous  course  of  urethra  or  if  such  exists,  of  false  jjassa^c  or 
fistula  and  render  the  operation  easier.  Suprapubic  retrograde  passage 
of  filiform  or  guide  by  Sinclair's  method  or  by  the  method  of  supra- 
pubic cystotomy  is  often  necessary  to  bring  the  proximal  aiifl  distal 
portions  of  the  urethra  into  proper  anastomosis. 

8.  Excision  of  the  stricture  or  urethroplasty  is  necessary  for  impas- 
sable nodular,  scar  tissue  strictures  completely  replacing  the  walls  of 
the  canal.  The  lumen  of  the  passage  is  restored  either  by  partial 
suture  or  transplantation  of  mucosa  in  the  method  described  on  page 
407.  On  the  other  hand,  it  is  noted  tliat  the  majority  of  strictures  are 
inflammatory  and  that  the  end  result  of  any  excision  operation  must 
in  greater  or  lesser  degree  be  an  annular  traumatic  stricture,  which 
probably  without  single  exception,  is  the  most  intractable  form  of 
stricture.  Therefore,  the  application  of  excision  is  deservedly  a  ques- 
tion of  the  greatest  possible  doubt. 

Comparison  of  the  Various  Types  of  Stricture  for  Dilatation  and  Opera- 
tion.— The  following  facts  are  revealed  in  such  a  study : 

1.  Strictures  of  the  meatus  wdth  s}7nptoms  require  meatotomy 
always  along  the  floor  and  at  times  meatal  internal  urethrotomy. 

2.  Open  strictures  from  19  Fr.  upward,  and  close  strictures  from  10 
to  19  Fr.  both  inclusive,  indicate  gradual  dilatation.  In  the  anterior 
urethra  the  elasticity  of  the  tissues  may  require  internal  urethrotomy, 
but  in  the  posterior  urethra  such  elasticity  rareh^  occurs  and  the  infil- 
tration may  be  relieved  without  internal  uretlirotomy. 

3.  Tight  strictm*es,  9  Fr.  and  smaller,  may  often  call  for  gradual 
dilatation  unless  combined  with  urethritis  or  a  complication,  when 
open  operation  and  drainage  are  required,  especially  in  the  deep  lu-ethra. 
Internal  urethrotomy  is  often  the  sole  means  of  then-  relief  in  anterior 
urethra. 

4.  Impassable  strictures  require  combined  external  and  internal 
urethrotomy  excision  and  urethroplasty,  if  not  extensive.  Sinclair's 
method  or  the  older  suprapubic  cystotomy  and  retrograde  sounding 
of  the  deep  urethra  to  the  stricture  are  often  required. 

5.  New  succulent  uncomplicated  infiltration  if  not  less  than  one  or 
two  months  old,  should  be  dilated. 

6.  Irritable  infections,  cicatricial  deposits  with  urethritis,  other 
complications  such  as  urinary  fever,  abscess,  sinus  and  sepsis  always 
require  open  operation  and  drainage. 

With  this  brief  review  of  the  various  forms  and  indications  of  the 
treatment  of  stricture  the  detailed  technic  of  each  remains  to  be 
considered. 

NONOPERATIVE  TREATMENT  OF  STRICTURE. 
Dilatation. 

Varieties  are  two :  (1)  Gradated  dilatation,  by  which  is  meant  the  pass- 
ing of  instnmients  of  slowly  advancmg  diameter  at  definite  periods 
whose  interval  is  determined  by  the  character  of  the  stricture  itself, 


366 


TREATMENT  OF  STRICTURE  OF  THE  URETHRA 


and  its  behavior  under  this  treatment;  and  (2)  continuous  dilatation, 
by  whieh  is  implied  the  passinjj;  and  residenee  of  an  instriunent  in  the 
stricture  and  bladder  for  a  day  oi- 1\\().    It  is  ai)])li("(l  lo  the  use  of  whale- 


Fk..   yo. — Cua\ilati()ii. 


bone  filiform  ,c;uides  in  tii^iit  strictures  without  irrita})ility,  infection  or 
eom])lications. 

Indications. — Aside  from  the  following  special  principles  it  is  well 
to  remeinl)er  that  it  is  a  good  rule  to  make  a  reasonal)le  effort  to  dilate 


Fkj.  97. — Elongation. 


all  strictures.  Excej^tions  to  this  ])rinciple  are  (1)  when  drainage  is 
indicated  as  a  means  of  benefiting  the  posterior  urethra  and  bladder; 
(2)  when  the  stricture  is  smaller  than  7  Fr.  in  caliber  because  most  of 
these  cases  are  complicated  and  are  benefited  by  open  operation;  (3) 


NONOPERATIVE  TREATMENT  OF  STRICTURE 


307 


when  a  stricture  is  liigli  clasti(;  and  docs  not  rcinain  dilated,  and  (4) 
when  complications  coexist  with  the  stricture.  The  followiii{(  other 
general  principles  as  to  choice  between  dilatation  anrl  f)i)eration  are 
important. 


Fig.  98. — Elevation. 


Fig.  99. — Depression. 


Instruments.  —  For  dilatation  there  are  two  classes  of  instrument 
available:  (1)  woven  or  flexible  and  (2)  metal  or  rigid.  The  flexible 
instruments  include  whalebone  filiform  guides,  woven  filiform  guides, 
Bank's   whalebone   dilators,   V.    C.    Pedersen's   whalebone   dilators. 


368 


TREATMENT  OF  STRICTURE  OF  THE  URETHRA 


woven  olive-pointed  dilators,  preferably  those  Avith  cores  filled  with 
lead  shot,  woven  olive-pointed  catheters  and  an  assortment  of  woven 
caThcTers.    Tlii'  metal  instnimeiits  are,  ])\  clioici^,  the  author's  tunneled 


Fig.  100. — Penetration. 


and   (grooved  irrigating  sounds  and  irrigating  standard  sounds  and 
Kollmann's  mechanical  dilators,  either  irrigating  or  nonirrigating. 

Author's  Irrigating  Staiidard  and  Benique  Sounds.- — Irrigation  of 
the  bladder  after  passing  a  sovmd  may  be  done  with  silver  or  other 


Tig.  101. — Rotation. 


t.^^pe  of  catheter,  as  described  in  subsequent  paragraphs  on  page  374,  as 
the  "Two-journey  Plan,"  with  the  disadvantage  of  two  procedures  to 
accomplish  one  object,  which  should  be  combined  with  the  passing  of  the 


NONOPERATJVE  TREATMENT  OF  STRICTU/iE 


309 


sound  itself,  as  stated  in  the  original  discussion  by  the  writer. ^  After 
considerable  study  and  experimentation,  a  sound  has  b(!en  j^roduced 
which  corresponds  to  the  following  description  from  No.  18  V.  upward. 


Evacuation. 


The  irrigating  tube  is  a  silver  catheter,  of  the  same  size  for  the  entire 
series:  10  Fr.  It  runs  through  the  shaft  from  the  base  of  the  curve  to 
the  nipple  of  the  handle,  at  which  it  receives  the  rubber  tube  from  the 
irrigator.    Actual  practice  shows  that  the  necks  of  most  bladders  seize 


Fig.  103. — -Irrigation. 


the  sound  in  front  of  the  opening  so  that  the  irrigating  fluid  is  deli^'e^ed 
exactly  upon  the  floor  of  the  bladder.  In  a  few  bladders  it  is  necessary 
to  push  the  sound  in,  or  to  rotate  it  or  to  depress  the  handle  in  order 


24 


1  Trans.  Am.  Urol.  Assn.,  1909,  p.  111. 


370  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

to  disengage  the  opening  of  the  tube  from  the  nuieous  membrane. 
The  diameter  of  tlie  silver  catheter,  10  F.,  is  ample  for  evacuation  of 
thick  contents  and  for  irrigation  with  due  rapidity. 


Figs.  104,  A  and  B. — Author's  irrigating  standard  and  Beniqu6  sounds  and 
tunneled  and  grooved  irrigating  sounds.  Nos.  7,  8,  9,  10,  11,  12  are  made  of  steel 
tubing,  nickel  plated,  opening  on  side  in  order  to  clear  the  groove  (M,  Fig.  104,  A). 
Nos.  13,  14,  15,  16,  17,  18,  19,  20  open  on  the  convexity  of  the  curve  (M,  Fig.  104,  B). 
Nos.  8,  9,  10,  11,  12  taper  to  7  at  the  end,  in  Nos.  13,  14,  15,  16,  17  the  taper  is  six 
numbers  uniformly  (Fig.  104,  A).  Only  No.  18  and  larger  are  double  tapered  in  a 
No.  "N"  sound,  the  curved  portion,  i.  c,  between  C  and  D  would  increase  from 
"  A^'-B"  at  C  to  "A''"  at  D,  the  portion  between  D  and  E  is  of  uniform  circumference 
"  N,"  and  the  portion  between  E  and  F  is  also  of  uniform  circumference  but  smaller, 
i.  e.,  " N^-3"  (Fig.  104,  B).  In  all  sizes  the  diameter  of  tunnel  and  groove,  the  handle 
and  the  rubber  hose  fitting  are  the  same.  No.  13  and  larger  have  a  silver  tube  (5), 
which  is  the  same  in  all  sizes,  7  Fr.  (Fig.  104,  B.) 


The  nipple' is  of  uniform  size  for  the  entire  set  and  is  tipped  with  a 
cone-shaped  collar  for  rubber  tubing  an  inch  in  diameter.  This  uni- 
formity saves  trouble  in  comiections,  as  this  size  of  rubber  tube  is 
common  on  irrigators  and  hand  syringes. 

The  handle  is  the  shell-variety  commonly  set  on  many  instruments, 
and  does  not  vary  from  sound  to  sound. 


NONOPERATIVE  TREATMENT  OF  HTRICTURE  371 

The  shaft  is  of  the  double  taper  type  introduced  by  Dr.  Chetwood.^ 
The  first  ?y\  inches  next  to  the  handle  are  three  sizes  smaller. than  the 
main  shaft,  which  then  passes  forward  at  full  size  for  4  inches  until  the 
base  of  the  curve  is  reached,  thus  making  the  straight  shaft  1\  inches 
long. 

The  curve  is  on  the  radius  of  the  nonirrigating  standard  sound  1| 
inches.  The  length  of  the  curve  is  a  trifle  more  than  90°,  which  is  also 
standard.  The  taper  of  the  curve  is  uniformly  6  sizes  from  the  base  to 
the  tip,  so  that,  for  example,  size  26  F.  is  20  F.  at  the  beak.  In  the 
writer's  experience  this  taper  is  the  most  convenient  because  the  curve 
is  almost  entirely  through  the  stricture  before  dilatation  begins. 

In  Benique  sounds  the  first  degrees  of  the  instrument  are  also 
tapered  6  sizes,  so  that,  for  example,  a  No.  26  F.  instrument  is  20  F. 
at  the  point.  The  catheter  passes  along  the  curve  to  a  point  correspond- 
ing with  a  straight  line  projected  through  the  straight  shaft  until  it 
cuts  the  curve.  Thus  the  point  of  emergence  will  be  just  above  the 
bladder  floor,  as  in  the  other  two  forms.  Although  in  the  Benique 
sound  the  tunnel  is  not  straight,  in  having  only  end-openings  it  may 
readily  be  cleansed.  The  obtm-ator  is  of  the  form  described  excepting 
that  the  first  few  inches  of  the  shaft  are  of  flat  spring-metal. 

The  obturator  consists  of  a  small  plug  ground  to  fit  the  opening  at 
the  base  of  the  curve,  mounted  on  a  long,  rigid  wire  with  a  loop  handle. 
A  little  metal  plug  fits  into  the  Imnen  of  the  nipple,  thus  steadying  the 
obturator  at  this  point.  In  order  to  prevent  the  obtiu-ator  from  twist- 
ing, a  device  like  a  simplified  bayonet-catch  has  been  provided  between 
the  nipple  and  the  handle  of  the  obturator.  In  order  to  prevent  the 
sharp  corner  of  the  obturator  seen  in  AA,  Fig.  104,  from  projecting 
and  cutting  the  patient  if  in  the  inverted  position,  the  slot  of  the 
bayonet-catch  has  been  made  very  long  and  the  plug  on  the  handle 
of  the  obturator  set  forward  a  corresponding  distance.  Thus  if  the 
obturator  is  wrongly  inserted  the  plug  will  prevent  the  obturator  from 
being  seated  home  at  all  until  it  is  rotated  so  that  the  peg  is  in  the  slot. 
When  the  obturator  is  set,  in  order  to  prevent  any  sharp  edges  the 
siu-face  of  the  obturator  has  been  convexed  and  the  openmg  in  the 
silver  tube  concaved. 

"One-journey  Plan"  of  Vesical  Irrigation. — These  sounds  permit  this 
technic  perfectly. 

The  manner  of  using  irrigating  sounds  is  as  follows :  After  thoroughly 
boiling,  the  obturator  is  examined  to  see  that  it  is  freely  movable  and 
then  pushed  into  position  and  locked.  The  sound  is  then  lubricated 
and  introduced  into  the  urethra  in  the  usual  manner.  It  is  well  to 
place  the  little  finger  through  the  loop  in  the  handle  so  as  to  be  sure 
that  the  obturator  does  not  slip.  For  the  same  reason  it  is  also  well  to 
make  the  final  pressm'e  upon  the  sound  by  means  of  the  obturator- 
handle,  which  is  stout  enough  to  permit  thereof.  After  the  sound  has 
remained  in  five  or  ten  minutes  the  obtm*ator  is  withdrawn  and  a  flow 
of  urine  follows,  and  a  recepta  :le  should  be  at  hand  to  catch  it. 

1  Chetwood  and^Keyes:    Venereal  Diseases,  1900,  p.  126. 


372  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

The  irrigator,  previously  filled  with  warm  aiitise})tic  fluid,  is  now 
eonneetwl  with  the  nipple  ijently  so  that  ehafinu'  the  hladder  with  the 
open  end  of  the  channel  shall  not  occur.  It  is  best  to  have  a  three- 
inch  piece  of  rubber  tube  to  slip  over  the  nipple  readily,  but  water- 
tight. Into  this  the  conical  tip  of  the  syringe  or  irrigator  may  be 
sli))])ed  without  disturbing  the  sound.  Although  sini])le,  this  is  an 
ini])ortant  d(>tail. 

Under  gentle  ]:>ressure  a  few  ounces  of  fluid  at  a  time  are  run  into 
and  out  of  the  bladder.  If  the  flow  does  not  immediately  start  it  is 
}:)robably  due  to  the  fact  that  the  mucous  membrane  of  the  bladder 
floor  lies  too  tightly  against  the  bladder  end  of  the  tunnel.  Correction 
of  this  difficulty  has  already  been  noted  under  maimer  of  introduction. 
After  the  bladder  has  been  irrigated  it  is  finally  filled  with  the  fluid 
and  the  sound  without  the  obturator  is  withdrawn.  The  i)atient  i^ 
then  allowed  to  evacuate  the  antiseptic  at  once  or  to  carry  it  away 
with  him  in  his  bladder  for  e\'acuation  a  fiuarter-hour  or  a  half-hour 
later. 

The  results  of  using  irrigating  sounds  are  not  only  protection  against 
dangers  of  sound-passing,  but  distinct  promotion  of  the  comfort  and 
reassurance  to  the  patient.  The  intelligent  ])atients  state  that  they 
never  have  felt  so  comfortable  after  the  i)assing  of  a  soimd  as  after 
these  irrigations  and  evacuations  of  a  warm  simple  antiseptic  fluid. 

Irrigating  Tunneled  and  Grooved  Sounds. — ^The  necessity  of  always 
washing  bladder  and  urethra  after  instrumentation  led  the  writer  to 
devise  an  irrigating  tunneled  and  grooved  sound  laid  down  on  the  lines 
of  the  original  Van  Buren-Gouley  sound.  Hitherto  the  only  irrigating 
instrmnent  which  might  be  used  as  a  sound  was  the  silver  catheter. 
The  writer  has  devised  a  tunneled  and  grooved  sound  by  taking  two 
steel  tubes  for  the  small  sizes  and  by  cutting  a  segment  out  of  the  wall 
of  each  which  wlien  brazed  together  gi\'e  the  shaft  of  the  sound,  and  the 
groove  of  the  sound. 

In  order  to  perser^■e  the  plan  of  the  irrigating  standard  sound  just 
described,  the  curvature  is  uniformly  of  If  inches  radius,  the  length 
of  the  curve  is  approximately  1  inch  shorter  than  that  of  the  standard 
sound.  To  compensate  for  this  shortening  of  the  tip  the  straight  i)art 
of  the  shaft  is  elongated  1  inch.  The  taper  of  the  curve  is  uniformly 
six  French  nimibers  in  all  sizes  from  13  to  20.  Sizes  8  to  12, 
inclusive,  however,  taper  to  No.  7  at  the  point.  By  this  plan  of  six- 
size  taper  where  possible  the  dilatation  is  made  \'ery  gradual.  For 
example,  size  18  F.  is  at  the  tip  12  F.,  at  the  middle  of  the  curve  15  F., 
and  at  thirds  of  the  distance  between  the  tip  and  the  middle  of  the 
curve  13  and  14  F.,  respectively,  and  at  thirds  of  the  distance 
between  the  midpoint  and  the  straight  shaft  16  and  17  F.,  respec- 
tively. Also,  for  example,  size  10  F.  is  7  F.  at  the  tip  and  8^  F. 
at  the  midpoint,  and  so  on  for  the  whole  series  of  sounds.  This  careful 
uniformity  of  taper  is  of  great  service  in  using  the  sounds,  for  a  stricture 
which  has  taken  8  F.  will  accept  almost  the  half-beak  of  the  10  F. 
instrmnent  before  the  real  dilatation  begins,  and  a  stricture  which  has 


NONOPERATIVE  TREATMENT  OF  STRICTURE  373 

taken  Ki  F.  will  engage  almost  two-thirds  of  the  beak  of  an  18  F. 
soinid  before  stretching  ensues.  Thus  far  greater  safety  in  the  us(;  of  the 
instruments  is  gainec]. 

It  is  not  necessary  to  have  an  office  set  consisting  of  all  sizes.  The 
author  has  found  the  even  numbers  sufficient,  namely,  8  to  26  F., 
inehisive.  Ordinarily  No.  20  F.  would  be  the  largest  required.  IVo 
patients,  however,  who  refused  urethrotomy  had  dense  extensive 
strictures  which  required  for  safety  the  other  nimibers  of  the  series 
stated,  namely:  22,  24  and  20  F. 

The  shafts  are  of  uniform  size  from  the  base  of  the  curve  to  the  handle 
until  size  18  F.  and  larger  are  reached.  Then  the  double-taper  plan  of 
Chetwood  is  used. 

The  tunnels  of  the  tips  are  of  uniform  diameter  from  the  smallest 
to  the  largest  sounds,  namely,  a  trifle  over  the  diameter  of  the  ordinary 
whalebone  filiform  guide.  This  plan  prevents  wabbling  of  the  larger 
sizes  upon  the  filiform  and  accustoms  the  operator  to  a  uniform  feel 
of  the  action  of  the  sounds  in  passing  along  the  guides — a  very 
important  detail.  All  tunnels  are,  moreover,  f  inch  long,  which  gives 
relatively  extensive  cones  for  the  tips  of  the  sounds.  The  long-tunneled 
tip  follow^s  the  direction  of  the  filiform  better  and  really  prevents  the 
tendency  of  short  tunnels  to  cut  or  buckle  the  filiform. 

The  grooves  begin  at  the  proximal  ends  of  the  tunnels  and  extend 
throughout  the  shaft  to  the  handle  and  are  likewise  of  uniform  width 
and  depth,  i.  e.,  large  enough  to  accommodate  the  standard  filiform 
guide.  This  excess  of  space  between  the  filiforms  and  the  grooves  is 
ample  for  the  purposes  of  urethrotomy,  namely,  of  guiding  the  knife 
and  the  director,  should  such  be  necessary. 

Irrigation  is  provided  for  in  sounds  No.  13  F.  and  larger  by  silver 
catheters  of  uniform  size  (7  F.)  extending  from  the  base  of  the  curve 
of  the  tip  to  the  rubber  hose-fitting  in  the  handle  and  opening  into  the 
groove  at  the  base  of  the  curve.  Sizes  7  to  12  (both  inclusive)  are 
hollow  throughout  and  in  order  to  clear  the  groove  have  the  opening 
on  the  side  also  at  the  base  of  the  curve.  This  is  necessary  because  a 
separate  silver  tube  could  not  be  incorporated  into  such  small  sizes. 

The  handles  of  the  sounds,  including  the  hose-connections  and  the 
obturators  of  the  sounds,  are  the  duplicates  of  the  types  used  in  the 
standard  sounds  described  in  the  first  part  of  the  article. 

The  advantage  of  irrigating  tunneled  and  grooved  sounds  lies  in  the 
fact  that  it  permits  treatment  of  the  bladder  through  the  same  instru- 
ment used  to  dilate;  in  other  words,  instrmnentation  reduced  to  a 
minimum,  which  in  most  strictures  is  of  extreme  importance,  because 
the  reflexes  due  to  irritation  are  matters  of  moment  in  all  stricture- 
instriunentation . 

The  prevention  of  rust  in  the  calibers  of  the  small  steel  tunneled 
and  grooved  irrigating  sounds  requires  that  they  should  be  di'ied  as 
well  as  possible  in  dry  heat,  or  have  the  moistm'e  blown  from  them, 
and  then  the  obturator,  dipped  deeply  into  the  liquid  albolene,  should 
be  seated  home.  In  this  way  the  lumen  is  kept  free  from  moistm-e, 
oiled  internally  and  remains  rustfree. 


3<4  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

Soft,  flexible  iiisfniiiinih'  for  irrifiafi'in  are  as  follows:  An  olive- 
pointed  woven  eatheter  is  taken  and  threaded  over  a  woven  dilator, 
connuon  or  lead-eore.  Into  a  very  small  size  catheter  whalebone 
gnides  may  be  passed  with  advantage  as  obtnrators.  After  the  stric- 
ture has  been  i)assed  the  obturator  is  reniovetl  and  the  bladder  duly 
filled.  Y'l^.  105  shows  the  catheter  with  its  lead-core  dilator  as  obtu- 
rator seated  fully  home.  It  will  be  noted  that  the  gentle  cone  of  the 
tip  of  the  catheter  is  followed  by  a  small  area  of  its  length  correspond- 
ing with  the  tip  of  the  dilator,  which  is  relatively  less  sui)])()rted  by 
the  dilator.  This  "give"  or  compressibility  only  a<lds  to  the  gentleness 
of  the  dilatation  and  is  an  advantage.  As  a  rule,  a  difference  of  about 
0  to  11  sizes  French  occurs  between  the  outside  diameter  of  the  catheter 
and  that  of  the  dilator;  for  example,  a  22  F.  catheter  has  a  bore  of  12 
or  1 1  F.,  and  tlierei'ore  needs  a  <liIator  of  either  of  these  sizes. 

"Two-journey  Plan"  of  Vesical  Irrigation. — In  irrigatuig  the  bladder 
dm'ing  dilatation  of  stricture  another  method  is  the  "Two-journey 
Plan."  The  dilator  is  passed,  and  after  remaining  the  required  time, 
withdrawn,  and  a  catheter  of  slightly  smaller  size  substituted.  This 
double  invasion  of  the  passage  is  to  be  avoided  whenever  possible, 
but,  after  all,  it  is  better  than  the  omission  of  the  artificial  urine  in 

^E     F 

^±l::z:^z:::::::iz-zzzz,^s:::::z::^^^ 


Fig.  105. — A  B,  represents  the  olive-point,  woven,  lisle-tliread  catheter,  and  C  D 
represents  the  cone-point,  lead-core,  woven,  lisle-thread  dilator,  used  as  an  obturator, 
seated  home  in  the  lumen  of  the  catheter,  extending  from  the  open  funnel-end  D,  to  the 
eye  at  E.  The  failure  of  the  point  of  the  obturator  to  support  the  wall  of  the  catheter 
just  back  of  the  eye  is  clearly  shown,  E  F. 

order  to  sterilize  the  bladder  and  wash  out  the  urethra.  The  use  of 
the  irrigating  sounds  in  order  to  accomplish  the  same  ends  is  familiar 
from  the  pre^•ious  description. 

There  is  analogy  between  the  Two-journey  Plan,  noted  above,  and 
the  technic  of  the  old-fashioned  nonirrigating  cystoscope,  which 
required  the  bladder  to  be  prepared  before  and  frequently  after  the 
cystoscopy  with  the  helj)  of  a  catheter.  This  necessitated  the  passing 
of  two  instrmnents,  and  if  bleeding  followed  the  introduction  of  the 
cystoscope  the  field  could  not  be  cleared  through  the  sheath  of  this 
instrument  but  only  through  a  catheter  reintroduced  after  withdraw! 
of  the  examining  instriunent.  The  disadvantages  of  this  doubling  of 
the  offense  to  the  urethra  and  bladder  are  at  once  obvious,  esi)ecially 
when  one  remembers  that  they  are  both  irritable  structures  when 
inflamed,  as  is  often  the  case  in  patients  requiring  cystoscopy  or  dilata- 
tion of  stricture.  The  irrigation  of  the  bladder  through  the  chief  of 
the  cystoscope  or  through  the  siher  catheter  within  the  irrigating 
sound  is  at  once  a  rational  i)rocedur€,  and  by  lea^•ing  the  bladder  full 
of  irrigating  fluid  the  patient  in  Natm-e's  own  way  irrigates  his  own 
lu'ethra,  quiets  traumatism,  and  limits  reflex  action. 


NONOPERATIVE  TREATMENT  OF  /STRICTURE  375 

Selection  of  Type  of  Dilator.  ^Selection  of  dilator  means,  in  other 
words,  woven  and  flexible,  versus  rigid  and  metallic-  forms.  The 
factors  of  the  decision  in  brief  are  the  extent  of  the  stricture  along  the 
urethra,  the  thickness  of  the  stricture  walls,  the  tortuosity  of  the  lumen 
and  the  amount  of  the  discharge  (partially  synonymous  with  the  degree 
of  inflammation  present).  Long,  thick,  tortuous  and  irritable  or  inflam- 
mable strictures  certainly  indicate  soft  instruments  until  they  are 
raised  to  size  20  French  in  diameter,  when  they  are  open  strictures,  and 
may  frequently  be  benefited  by  resort  to  steel  instruments.  lielapse 
of  a  stricture  after  a  cutting  operation  is  usually  very  tortuous,  thick, 
inelastic  and  dense,  and  requires  soft  instruments.  Sometimes  only 
the  soft  instruments  may  be  used,  no  matter  what  the  diameter  of  the 
stricture  may  be.  This  is  particularly  true  where  the  tortuosity  or 
alteration  in  the  course  of  the  canal  is  great.  Frequently  a  stricture 
wjiich,  without  pain,  takes  a  28  French  flexible  instrument,  refuses  a 
24  French  steel  instrument,  excepting  at  the  cost  of  force  and  pain. 
The  reason  is  at  once  obvious:  the  steel  instrument  not  only  dilates 
the  caliber  centrifugally,  but  also  spreads  the  canal  forcibly  from  great 
tortuosity  to  a  relatively  straight  line.  In  these  cases  the  use  of  a 
steel  instrument  is  a  mistake,  because  it  causes  sufficient  traumatism 
to  add  to  the  scar  tissue.  Stricture  of  the  prostatic  m^ethra  and  neck 
of  the  bladder,  following  prostatectomy,  always  requires  soft  instru- 
ments. Strictures  which  cover  a  short  length  of  the  canal  are  bandlike 
or  ringlike  in  form,  and  are  best  treated  with  steel  instruments.  Tor- 
tuous strictures,  with  thin  walls,  after  having  been  dilated  with  soft 
instruments,  are  not  uncommonly  benefited  by  steel  instruments  and 
massage. 

Forecare  of  the  Patient. — ^The  surgeon  must  be  concerned  in  the 
treatment  of  the  kidneys,  urine  and  urethra,  and  embrace  the  admin- 
istration of  urinary  antiseptics  and  of  reasonable  irrigation  of  accessible 
urethral  mucous  membrane.  The  preliminary  attention  to  the  stricture 
itself  concerns  the  local  use  of  styptics  (adrenalin),  antiseptics  (weak 
solutions  of  nitrate  of  silver)  and  at  times  local  anesthetics  (weak  com- 
binations of  cocain,  eucain  and  alypin) .  Meatotomy  is  an  important 
step,  not  only  for  permitting  the  passage  of  suitable  instruments,  but 
also  for  granting  due  drainage  of  the  canal.  There  is  no  doubt  that  a 
small  meatus  invites  stricture  in  the  third  region  of  the  urethra  by 
retarding  the  drainage  of  gonococcal  pus,  and  thus  by  increasing  the 
penetration  of  the  disease. 

Gradual  Dilatation. — Institution. — The  time  for  begmning  gradual 
dilatation  of  stricture  is  the  same  as  the  interval  advised  between 
separate  treatments,  that  is  to  say,  from  tliree  to  seven  days  after  the 
original  diagnostic  examination,  which  is  in  itself  usually  a  distinct 
dilatation  through  the  employment  of  bougies-a-boule,  m*ethroscope, 
sounds  and  the  like.  The  shorter  interval  may  be  taken  in  strictures 
without  inflammation  and  many  symptoms,  but  in  the  long  run  it  is 
wiser  to  give  the  mucous  membrane  full  recovery  for  a  time  bet^-een 
treatments.    The  interval  is  commonly  not  less  than  five  days  apart. 


376  TREAT  ME  XT  OF  STRICTURE  OF  THE  URETHRA 

Preliminary  Meatotomy  is  required  whoiieNor  the  meatus  is  so  small 
as  to  ii;i\e  syniptoius  iu  itself  or  as  to  prevent  tlie  passage  of  any  but 
instruments  too  small  to  benefit  the  proximal  urethra.  It  is  always 
performed  on  the  floor  of  the  meatus  imless  anatomical  defect  has  laid 
down  a  shallow  or  dee])  rediii)lication  of  the  channel  which  is  usually 
dorsal  and  l)lind  at  its  i)roximal  limit.  In  such  a  case  both  dorsal  and 
ventral  enlargement  of  the  meatus  nmst  be  cautiously  and  completely 
done.  Its  technic  is  detailed  under  internal  urethrotomy  but  the  little 
wound  should  be  allowed  to  heal  fully  before  dilatation  is  begun, 
otherwise  the  irritation  of  the  o]xmi  incision  will  frequently  jH'ovoke 
spasm  of  the  dee])  urethra  and  neck  of  the  bladder  which  will  interfere 
with  the  subsequent  steps.  Part  of  the  aftertreatment  of  meatotomy 
is  to  ])ass  straight  sounds  through  the  enlarged  opening  until  the  epi- 
thelium has  covered  in  the  sm-faees  of  the  woimd,  otherwise  dosiu'e  of 
the  incision  and  failure  of  the  ojDeration  will  follo\\-.  Intercurrent 
meatotomy  is  a  term  applied  to  enlargement  of  the  meatus  at  a  sub- 
sequent i)eriod  of  the  dilatation  of  strictiu'cs  which  require  immediate 
enlargement.  When  the  latter  has  been  carried  up  to  the  limits  of  the 
meatus,  the  outlet  is  incised  in  the  usual  way.  Thus,  in  illustration,  a 
close  strictiu"e  of  12  ¥r.  may  be  brought  up  to  the  limit  of  the  meatus, 
say  20  Fr.,  and  this  may  be  divided  to  30  Fr.  for  the  remainder  of  the 
treatment. 

Open  and  Close  Strictures  which,  as  i3re\'iously  stated,  respectively 
include  20  Fr.  and  larger,  and  10  to  19  Fr.  inclusive,  are  suited  to  dila- 
tation with  instrmiients  without  a  guide  in  most  cases.  In  selecting 
the  first  instrument  the  same  diameter  or  one  size  smaller  than  the 
bougie-a-boule  which  has  passed  the  stricture  sliould  be  emi^loyed, 
and  the  sound  left  in  jDlace  for  at  least  five  minutes.  This  treatment 
trains  the  mucosa  not  only  to  dilatation,  but  also  to  a  certain  amount 
of  extension  in  that  sounds  do  that  which  the  bougie-a-boule  does  not, 
that  is,  stretch  the  urethra  in  length  as  well  as  in  diameter;  in  other 
words,  reduce  the  tortuosity  as  well  as  the  narrowing  of  the  infiltration. 
After  tolerance  has  thus  been  developed,  advance  in  diameter  should 
be  by  one  number,  or  at  most  two,  so  as  to  avoid  divulsion  of  even 
moderate  degree.  When  the  limit  of  the  meatus  which  is  naturally  one 
of  the  narrowest  parts  of  the  canal,  as  stated  under  this  heading,  is 
reached,  the  question  M-hether  or  not  intercurrent  meatotomy  should 
be  done  rests  on  the .  size  of  the  meatus  itself  primarily,  and  on  the 
behavior  of  the  stricture  secondarily.  In  other  words,  a  distinctly 
small  meatus  must  be  opened,  but  a  stricture  which  has  been  dilated 
to  25  Fr.  as  an  illustration  (because  the  meatus  will  not  accept  a 
larger  instrmuent)  and  remains  in  j^erfectl}'  good  condition,  does  not 
ordinarily  indicate  a  meatotomy,  especially  if  a  urethroscopy  shows 
that  the  mucosa  about  the  stricture  is  in  good  condition.  If  otherwise, 
either  a  meatotomy  may  be  performed  and  the  stricture  dilated  to  30 
Fr.,  or  a  mechanical  dilator,  such  as  the  Kollmann,  may  be  employed 
for  the  remaining  period  or  an  internal  urethrotomy  ]^erformed  with 
the  ]Maisonneuve  or  Otis  instrument,  all  according  to  results  of  study 


NONOPEItATIVK  TR.KA.TMENT  OF  HTIUdTUUE  377 

of  the  lesion.  Retention  of  the  souiid  is  for  a  period  of  five  to  ten  minutes 
so  as  to  induee  complete  and  gradnal  destru(;tioii  of  the  fil)roiis  hands, 
by  the  principle  now  familiar  to  gynecolo<(ists  that  gradnaJ  stretching 
of  OS  uteri  is  more  lasting  and  safe  than  rapid.  Irrigation  of  the  bladder 
and  urethra  with  the  special  sounds  of  the  writer  has  already  been 
justified. 

Methods  of  Gradual  Dilatation  are  two:  (1)  with  rigid  or  metal  instru- 
ments, and  (2)  with  soft  or  flexible  instruments.  The  best  examples 
of  rigid  instruments  are  the  steel  sound,  bougie-a-boule  and  silver 
catheter,  and  of  flexible  instruments  the  many  types  of  silk  and  lisle- 
thread  gum-elastic  bougies-a-boule,  dilators  and  catheters. 

Technic  with  Metal  Instruments. — The  sound  is  taken  as  the  type  and 
the  manner  of  passing  it  into  the  bladder  without  a  guide  through  any 
stricture  is  as  follows:  Although  a  sound  may  be  passed  through  the 
small  calibers  of  close  stricture,  say  from  10  to  16  Fr.  caliber,  both 
inclusive,  it  is  hazardous  to  do  so  without  a  guide  except  with  soft 
instruments  which  are  in  these  cases  to  be  preferred. 

The  following  details  are  applicable  to  strictures  anj^vhere  in  the 
canal  and  perhaps  especially  to  those  of  the  posterior  urethra.  There 
are  cases,  however,  where  the  infiltration  is  in  the  anterior  urethra 
alone,  so  far  forward  that  it  is  inadvisable  to  pass  a  sound  into  the 
bladder.  For  such  cases  the  curved  sound  may  be  passed  only  to  the 
bulb  or  first  step  of  bringing  the  instrument  to  the  vertical  position, 
or  preferably  the  technic  of  passing  a  straight  sound  should  be  employed. 

The  same  preliminaries  are  respected  and  the  instrument  is  allowed 
to  drop  of  its  own  weight  into  the  urethra  while  the  organ  is  held  in 
the  vertical  position.  By  this  step  no  part  of  the  mucous  membrane 
is  traversed  more  than  that  of  the  bulb  and  anterior  canal,  and  any  risk 
of  deeper  invasion  at  once  avoided.  These  sounds  are  also  to  be  retained 
five  to  ten  minutes. 

After  the  preliminary  examination  has  been  completed  and  when 
possible  urinary  antiseptics  given  for  a  few  days  the  patient  makes 
his  next  visit,  passes  his  urine,  and  is  placed  on  the  operating  table 
with  his  feet  apart,  his  underclothing  drawn  downward  to  the  knees, 
and  rolled  upward  to  the  ribs.  With  sterilized  hands  and  instruments 
the  urologist  washes  the  glans  penis  and  meatus  with  boric  water,  and 
then  lubricates  the  sound  and  the  canal.  The  most  serviceable  lubri- 
cant in  the  writer's  opinion  is  boroglycerid,  to  which  various  anti- 
septics may  be  added  in  small  percentage  and  which  is  at  once  fluid, 
tenacious,  freely  soluble  and  definitely  lubricating,  and  even  m  itself 
antiseptic.  There  are  various  Irish  moss  lubricating  preparations 
which  are  also  valuable  provided  they  are  made  up  in  the  fluid  state, 
which  is  generally  not  the  case.  Ambidexterity  should  be  the  adjimct 
of  every  skilful  urologist,  otherwise  as  a  rule  the  operator  stands  on  the 
right  side  of  the  table  if  right  handed  and  on  the  left  side  if  left  handed, 
and  holds  the  penis  in  his  opposite  hand.  The  sound  is  held  over  the 
middle  line  of  the  body  Avith  the  shaft  parallel  with  the  abdomen  or 
the  table,  and  the  point  downward.    The  tip  is  engaged  m  the  meatus 


37S  TREATMEXT  OF  STh'fCTrh'E  OF  THE  URETHRA 

and  slides  into  the  canal  up  to  the  shaft  of  its  own  weight,  carrying 
it,  as  a  rule,  nearly  to  the  ])enoscrotal  angle.  This  ste])  is  called 
"Gravitation."  and  is  shown  in  Fig.  9G.  While  the  handle  is  now 
elevated  to  about  90°  with  the  table,  the  penis  is  gradually  threaded 
over  the  instrument,  whi-h  again  of  its  own  weight  is  allowed  to  drop 
downward  into  the  bulb  of  the  urethra.  This  ste])  is  termed  "Elonga- 
tion," and  is  detailed  in  Fig.  97.  Gentle  elevation  of  the  tip,  with 
the  handle  still  vertical,  will  disengage  it  from  the  depth  of  a  large 
bulb  and  enterit  into  the  membranous  urethra,  or  the  same  thing  may 
be  accomplished  by  causing  the  cur\c  of  the  instrument  to  hug  the 
pubic  arch  as  the  handle  is  ele^•ated  from  the  original  horizontal  to  the 
nearly  vertical  j^osition.  At  times  su])port  of  the  instrument  over  the 
base  of  the  scrotum  and  perineum  and  even  guidance  into  the  mem- 
branous urethra  with  the  finger  in  the  rectum  are  necessary.  This 
step  is  named  "Elevation,"  and  is  jjortrayed  in  Fig.  98.  The  handle 
is  depressed  without  force  and  without  encountering  resistance  until 
])arallel  with  the  table,  which  brings  the  curve  within  the  bladder.  The 
shaft,  still  within  the  urethra,  is  now  slowly  advanced  into  the  bladder 
for  3  cm.  These  steps  are  "Depression,"  Fig.  99,  and  "Penetration," 
Fig.  100.  Progress  of  the  soimd  through  its  ^•arious  stages  of  position 
through  the  arch  of  nearly  180°  should  be  as  nearly  as  possible  by  its 
own  weight  and  its  freedom  within  the  bladder  established  by  gentle 
rotation,  as  shown  in  Fig.  101,  entitled  "Rotation."  It  is  at  this  point 
that  the  irrigating  principle  of  the  writer's  sound  is  of  value  because 
the  bladder  may  be  left  full  and  evacuated  by  withdrawing  the  ob- 
tiu-ator  and  thus  entrance  into  the  bladder  cavity  established  and  next 
the  detail  of  irrigation  established  as  previously  described.  The  step 
of  "Evacuation"  is  shown  in  Fig.  102  and  that  of  "Irrigation"  in 
Fig.  103.  Thus  are  completed  the  eight  steps  of  the  consistent  process 
of  painless  introduction  of  the  sound  in  the  writer's  practice.  The 
sound  is  now  left  in  place  for  five  minutes,  withdrawn,  the  sedative  pill 
and  urinary  antiseptic  prescribed,  the  patient  directed  to  rest  a  few 
moments  against  the  possibility  of  hemorrhage,  allowed  to  go  home 
with  suitable  instructions  for  as  much  bodily,  urinary  and  sexual  rest 
as  possi])le. 

Technic  with  Soft  Instruments. — All  the  principles  previously  laid 
down  for  the  posterior  urethra  as  to  preparation  of  the  patient  and 
the  selection  of  a  flexible  dilator  of  the  same  or  smaller  size  as  that  of 
the  bougie-a-boule  already  passed,  again  apply.  Likewise,  the  advance 
in  diameter  of  not  more  than  two  sizes  from  treatment  to  treatment, 
the  retention  for  ten  minutes  and  preferably  the  irrigation  of  the  bladder 
and  urethra  by  the  plan  of  using  a  catheter  threaded  over  a  dilator, 
which  acting  like  the  obturator  of  the  silver  catheter  in  the  author's 
sounds,  is  withdrawn  for  the  inflow  and  outHow  of  the  antiseptic  fluid, 
are  preferred.  The  attitude  of  the  patient  and  position  of  the  surgeon 
are  the  same,  except  that  the  penis  is  held  almost  in  a  straight  line  and 
parallel  with  the  table.  The  olive-pointed  instrument  is  the  safest 
and  best  and  should  be  slightly  curved  with  the  hand  before  engaging 


NONOPERATIVE  TREATMENT  OF  STRICTURE  379 

it  in  the  meatus.  Fr()m  this  ])()int  it  is  very  gently  and  slowly  advanced 
witliout  resistance,  pain  or  })Iee(ling,  smoothly  and  evenly  until  it  is 
felt  to  pass  through  the  sphincter  muscles.  After  due  retention  the 
dilator  is  withdrawn  from  within  the  catheter,  flushing  of  the  bladder 
performed,  the  viscus  filled,  and  then  emptied  })y  the  patient  for 
cleansing  the  urethra  from  end  to  end. 

Soft  instruments  for  strictures  of  the  anterior  urethra  are  used  in 
the  same  manner  as  that  described  for  straight  steel  sounds.  The 
penis  is  held  upright  and  the  bougie  is  gently  passed  until  it  reaches  the 
bulbs.  Inasmuch,  however,  as  many  anterior  strictures  are  in  the 
bulbar  region,  it  is  best  to  confine  this  plan  to  infiltrations  anterior  to 
the  penoscrotal  angle,  and  to  treat  all  others  whether  strictly  in  the 
anterior  or  posterior  urethra  by  passing  the  sound  into  the  bladder. 

Aftertreatment  depends  on  the  form  of  dilatation  employed.  In  irrigat- 
ing dilatation  cases,  employment  of  flushing  of  the  bladder  and  urethra 
as  previously  noted  is  all  the  local  measure  necessary.  If  nonirrigating 
dilatation  is  practised  with  either  steel  or  flexible  dilators  it  is  well  to 
irrigate  the  urethra  with  a  small  rubber  catheter  in  anterior  urethral 
cases,  employing  hot  boric  acid  or  1  in  5000  nitrate  of  silver  solution,  or 
to  instillate  the  deep  urethra  with  the  Ultzmann  or  Bangs  syringe 
sounds  with  a  few  drops  of  the  same  silver  nitrate  solution  in  posterior 
urethral  cases.  The  systemic  aftercure  is  the  administration  of  urinary 
antiseptics  and  one  sedative  pill. 

Dilatation  of  Tight  Strictures. — Dilatation  of  tight  strictures,  which, 
as  stated  earlier  in  this  chapter,  include  those  which  require  a  filiform 
guide,  may  be  performed  with  either  metal  or  flexible  instruments, 
with  preference  for  the  latter  when  suitable  response  to  them  is  possible, 
that  is,  when  the  infiltration  is  not  too  dense  to  resist  the  instrument. 
In  both  posterior  and  anterior  urethra  all  the  preliminaries  detailed  for 
open  and  close  strictures  again  apply  with  added  force  especially  as 
concerns  knowledge  of  infectiousness  and  inflammation  in  the  mucosa, 
administration  of  urinary  antiseptics  and  local  treatment  of  the  urethra 
either  by  the  irrigating  principle,  or  by  the  direct  flushing  or  instilla- 
tion of  the  mucosa  with  syringe  and  catheter.  As  stated  under  the 
subject  of  close  strictures,  the  calibers  below  16  Fr.  had  best  be 
approached  with  a  filiform  guide — a  fact  fr^m  which  proceeds  the 
principle  that  a  tight  stricture  should  be  opened  from  the  filiform  stage 
to  at  least  16  Fr.  before  the  guide  is  abandoned  and  in  very  tortuous 
strictures  it  is  wiser  to  use  the  guide  even  up  to  20  Fr.  Tight  strictures 
of  the  anterior  urethra  may  be  dilated  but  rarely  remain  so,  so  that 
internal  urethrotomy  is  to  be  preferred  for  them. 

Technic  with  the  Irrigating  Tunneled  and  Grooved  Sounds. — ^Ha\Tng 
passed  the  filiform  guide  by  the  method  fully  mider  the  objective 
symptoms  of  tight  stricture,  the  sound  thoroughly  sterilized,  its 
obturator  freed  in  its  cannula,  and  lubricated,  is  threaded  over  the  fili- 
form, which  must  naturally  be  sufficiently  small  to  run  through  the 
tunnel  in  the  tip.  For  this  reason  it  is  best  to  have  the  filiform  guides 
not  larger  than  4  Fr.  in  diameter,  as  the  tunnels  are  5  Fr.  Those  which 


3S0 


TREATMENT  OF  STRICTURE  OF  THE  URETHRA 


are  2  feet  long  are  to  be  preferred,  and  are  passed  through  tlie  stricture 
until  about  four  inches  project  beyond  the  urethra,  making  a  total 
of  about  twelve  inches  distal  to  the  bladder  and  twelve  inches  within 
the  bladder,  l>ing  coiled  ii])  in  reverse  for  testing  the  ])r()gress  of  the 
sound.  The  sound  is  hekl  exactly  as  has  been  described  for  the  standard 
instrument  and  the  penis  supported  in  the  palm  of  the  hand  with  three 
fingers  while  the  index  finger  and  tlnnnb  hold  the  filiform  just  beyond 
the  curve  of  the  sound  already  engaged  in  the  urethra.  From  this 
])osition  the  sound  is  gently  pushed  over  the  filiform  with  the  thumb 
and  index  fing(>r  holding  the  latter  on  guard  for  any  catch  or  resistance. 


Fig.  106. — Passage  of  a  stricture  with  filiform  guides.  The  urethra  has  been  con- 
veniently filled  with  the  filiforms.  The  left  hand  supports  the  penis  and  all  the  guides 
except  the  one  which  in  the  right  hand  is  advanced  as  far  as  possible.  Each  filiform 
is  taken  in  turn  in  the  same  way  until  finally  one  passes  into  the  bladder.  '  (Original.) 

Should  such  occur  ])rogress  of  the  sound  is  stopped  and  the  filiform 
taken  and  either  pulled  out  or  pushed  in  a  centimeter  or  two  in  order 
to  establish  its  freedom  within  the  timnel  of  the  sound.  This  freedom 
must  be  unmistakable,  othenvise  it  is  possible  to  buckle  the  filiform 
upon  itself  and  thus  pass  the  sound  not  through  the  stricture,  but 
through  almost  any  other  point  of  the  canal  or  to  cut  the  whalebone 
guide. 

The  manner  in  which  a  filiform  may  fold  on  itself  should  be  under- 
stood.^ Fig.  107  illustrates  one  within  the  urethra  during  the  effort 
to  pass  a  deep  stricture.  As  a  preliminary  caution,  before  threading 
a  sound  on  the  filiform,  careful  palpation  will  ascertain  whether  the 


>  Pedersen,  V.  C:  New  York  Med.  Jour.,  November  20,  1909. 


NONOPERATIVE  TREATMENT  OF  STfifCTURE 


381 


filiform  has  folded  on  itself  and  turned  distally  toward  the  meatus. 
Diagnosis  of  the  condition  is  aided  by  asking  whether  the  patient  has 


Fig.  107. — The  anatomical  details  of  this  diagram  are  sufficiently  clear  and  require 
no  notation.  The  stricture  is  plainly  shown  just  in  front  of  the  bulb.  The  filiform  also 
is  clearly  represented  doubled  upon  itself  at  the  face  of  the  stricture  with  the  shorter 
element  almost  presenting  at  the  meatus. 


Fig.  108. — As  in  Fig.  107,  the  anatomical  details  of  this  diagram  are  sufficiently  clear 
to  need  no  notation.  The  strictiu-e  is  plainly  shown  in  front  of  the  bulb.  The  filiform 
also  is  clearly  diagramed  double  t^^ace  upon  itself  at  the  face  of  the  stricture  and  above 
the  sound.  The  straight  strand  of  the  filiform  also  appears  leading  from  the  urethra  and 
again  through  the  stricture  into  the  bladder  where  the  redundancy  is  coiled  within  that 
viscus,  thus  demonstrating  the  advantage  of  using  fih  forms  two  feet  long. 


382  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

felt  the  filiform  slide  through  stricture  and  sphincter  of,  and  finally 
coil  \vithin  the  bladtler.  Doubt  may  be  remo\ed  in  dealing  with 
ignorant  patients  by  finding  two  strands  of  filiform  playing  upon  each 
other  imder  the  finger,  or  under  the  eye  through  the  ur(>throscope. 

The  numner  in  which  a  filiform  may  be  doubled  twice  upon  itself 
is  shown  by  Fig.  lOS  with  the  sound  in  situ,  usually  by  inattention  to 
the  binding  of  the  sound  on  the  guide  and  the  displacement  of  the  free 
end  into  the  urethra  as  the  sound  progresses.  The  diagnosis  of  this 
accident  is  not  easy,  as  the  ])atient  can  lend  no  aid  and  the  urethroscope 
cannot  be  employed.  Careful  ]iali)ation  around  the  curNc  of  the  sound, 
especially  if  the  instrument  is  turned  from  side  to  side  a  little,  will 
reach  two  or  more  strands  instead  of  one  between  the  stricture  and  the 
tip,  with  none  for  a  short  distance  where  the  filiform  lies  in  the  tunnel 
and  the  groove.  The  tiu'uing  of  the  instrument  disengages  the  various 
strands,  as  a  rule,  and  withdrawal  soon  re\'eals  the  whalebone  as  it 
turns  backward  and  forward  over  the  soimd  so  that  it  emerges  from 
the  meatus. 

Having  freed  the  tunnel  and  filiform,  the  sound  is  now  pushed  gently 
forward  to  the  vertical  position,  then  into  the  membranous  lU'cthra 
and  stricture,  and  finally  into  the  bladder.  If  the  free  hand  is  required 
to  guide  the  sound  by  pressure  on  the  perineum  or  even  by  rectal 
palpation,  then  with  each  half-centimeter  or  centimeter  of  advance, 
the  freedom  of  the  filiform  within  the  timnel  must  be  tested  so  that 
without  doubt  it  is  shown  that  the  tip  of  the  instrument  is  following 
the  guide.  Having  reached  the  bladder  the  same  details  of  using  the 
irrigating  attachment  as  already  described  are  followed.  The  progress 
in  diameter  in  tight  strictures  is  usually  much  slower  than  in  open 
strictures,  on  the  ground  that  the  pathological  process  in  the  former  is 
not  only  more  profound  and  extensive,  but  also  because  the  likelihood 
of  complications  and  accidents  is  greater.  Thus  it  is  best  to  use  the 
same  size  of  sound  two  or  even  three  times  in  succession  before  adding 
to  the  diameter,  because  the  straightening  of  the  tortuosity  of  these 
strictures  is  an  element  to  be  reckoned  with. 

Technic  with  Nonirrigating  Tunneled  and  Grooved  Sounds. — If  these 
instruments  are  chosen,  then  the  urethra  should  be  Hushed  or  instillated 
with  weak  silver  nitrate  solutions,  1  in  5000,  with  a  soft  catheter 
passed  to  the  face  of  the  stricture  or  an  Iltzmann  syringe  or  a  Bangs 
syringe  sound  engaged  at  the  same  point.  Manifestly  all  three  pro- 
cedures reach  imperfectly  the  cavity  of  the  stricture  and  the  proximal 
mucosa  until  the  caliber  has  been  advanced  enough  to  j^crmit  these 
instnmients  themselves  to  pass. 

Technic  with  Soft  Instruments. — Many  tight  strictures  reciuire  the 
passage  of  one  or  two  filiform  guides  side  by  side  at  a  number  of 
sittings  until  finally  the  cone  or  olive-pointed  bougie  may  be  accepted. 
Excepting  with  extreme  caution  it  is  better  to  adhere  to  the  olive- 
pointed  bougie  or  catheter,  and  the  latter  with  one  or  two  filiform 
guides  inserted  as  obturators  is  the  instrument  of  choice  as  it  provides 
the  full  degree  of  irrigation.  The  general  procedure  does  not  vary 
from  that  just  described  for  stricture  of  large  caliber. 


NONOPERATIVE  TREATMENT  OF  STRICTURE  383 

Direct  Vision  Method,— The  Biu^rgcr'  technic  for  })assiri{i;  a  filiform 
with  his  direct  vision  operating  urethroscope!  is  detailed  under  iin-thro- 
scopy  on  page  050. 

Continuous  Dilatation. — Forecare  and  Preparation  are  the  same  as 
for  gradual  dilatation,  but  the  type  of  case  is  restricted  to  tight  stric- 
tures, because  those  of  other  caliber  are  far  more  wisely  treated  by 
other  methods.  The  instruments  are  practically  only  filiform  guides, 
as  the  use  of  catheters  for  this  purpose  has  been  practically  abandoned 
because  the  size  of  the  instrument  is  such  as  to  provoke  foreign  body 
urethritis  which  may  reach  marked  proportions.  1'he  filiforms  are 
passed  in  the  classic  manner  and  retained  for  twenty-four  hours  with 
the  excess  of  length  coiled  in  the  bladder  at  rest  where  they  do  no  harm 
if  the  thin  flexible  ones  are  chosen,  and  excite  only  a  little  frequency 
of  urination  which  may  not  be  due  to  their  presence  in  the  bladder  so 
much  as  in  the  stricture  zone  where  reflex  influence  is  excited.    One  or 


Fig.  109. — The  author's  modification  of  Banks'  whalebone  dilator.  The  instrument 
is  the  first,  third  and  fifth  from  the  top  and  shows  its  conical  form  from  the  filiform 
to  the  shaft.  The  Banks'  instrument  is  the  second,  fourth  and  sixth  from  the  top,  and 
shows  its  flattened  portion  just  before  the  shaft  is  reached. 

two  filiforms  thus  threaded  through  a  tight  stricture  will  swell  suffi- 
ciently to  open  it  several  numbers.  From  this  point  gradual  dilatation 
with  tunneled  and  grooved  irrigating  sounds  or  with  soft  instruments 
may  be  proceeded  with  in  the  usual  manner  until  the  canal  is  restored 
to  nearly  normal  condition.  The  dangers  are  those  of  the  presence 
of  the  filiform  guide  as  foreign  body,  namely,  inflammation  around 
the  stricture  and  along  the  urethra  and  the  direct  mechanical  spread 
of  the  infection,  of  which  both  augment  the  already-existmg  conditions. 
For  this  reason  it  is  infrequently  employed  and  is  not  a  preferred 
method  but  is  available  only  in  those  cases  of  old  tight  stricture 
without  infectiousness  and  complications  in  patients  who  cannot 
very  well  be  confined  to  bed  for  operation.  Particularly  to  be  avoided 
for  the  foregoing  reasons  is  the  use  of  catheters  for  continuous  dilata- 
tion because  instruments  of  any  size  by  contract  with  the  mucosa 
immediately  become  offending  foreign  bodies. 

Aftertreatment  of  dilated  stricture  may  be  called  both  immediate  and 
remote,  meaning  respectively  that  during  active  treatment  and  that 

1  Surg.  Gynec.  and  Obst.,  March,  1918,  No.  3,  v,  xxvi,  347-350. 


3S4      TREAT ^f EXT  OE  STINCTrRE  OE  THE  URETHRA 

after  full  falil)(.'V  has  \)vvn  i)r(»(liKi'(l.  In  the  immocliate  aftortroatnient 
(luring  active  treatnuMit  tlu'  ])atient  shoulil  lunt'  a  ])eri()(l  of  rest  in  the 
office  and  he  directed  to  observe  betAveen  treatments  rest  from  both 
active  and  passive  sexual  excitement,  and  rest  from  urinary  distiu'bance 
through  dietetic  indiscretion.  Urinary  antiseptics  are  indicated  for  the 
first  tAventy-four  houi"s  after  dilatation,  and  antis])asin(>dics,  for  the 
relief  of  vesical  si)asm,  are  ])rovide(l  by  the  free  drinking  of  water,  light 
diet  and  abstinence  from  alcohol  and  sexual  intercourse.  INIental 
reassurance  of  the  patient  is  very  necessary  as  to  the  facts  that  there 
will  be  for  a  day  or  two,  after  the  passage  of  the  sound,  some  ardor  and 
pain  on  lU'ination  and  erection  and  at  times  a  little  discharge,  of  which 
all  are  the  muivoidable  outcomes  of  invasion  of  a  mucous  membrane. 
In  the  remote  aftertreatment,  the  indication  is  avoidance  of  relapse 
of  the  stricture.  The  patient  should  be  taught  that  since  the  stricture  is 
fundamentally  only  a  cicatrix,  it  cannot  ordinarily  be  literally  removed 
from  the  ])assagewa>',  but  its  power  of  obstruction  may  be  corrected 
by  either  the  stretching  or  the  cutting,  lie  should  realize  that  like  all 
other  scars  urethral  stricture  tends  with  age  to  dry,  or  harden,  and 
shrivel  or  contract,  and  thus  to  reclose  or  reobstruct  the  lU'cthra. 
When  he  understands  that  this  is  the  law  of  all  scar  tissue  and  therefore 
the  law  of  strictin-e,  he  will  regularly  report  from  one  to  four  times  a 
year  for  observation  and  the  correction  of  any  slight  relapse.  It  is 
probable  that  the  majority  of  strictures  are  perfectly  safe  only  w'hen  a 
sound  is  passed  through  them  at  least  once  a  year. 

Electrolysis  of  Stricture. 

History. — One  of  the  earlier  English  authorities  was  R.  M.  Lawrance^ 
who,  in  1853,  said  concerning  stricture  of  the  urethra:  "In  this  com- 
plaint the  electrogalvanic  current  is  an  efficacious  remedy,  and  very 
little  pain  attends  the  application.  After  the  urethra  has  been  examined 
with  a  common  plaster  bougie,  to  ascertain  the  exact  position  of  the 
strictiire,  a  metallic  sound,  covered  with  gum-elastic,  and  having  a 
conical  silver  point,  should  be  very  gently  introduced  into  the  anterior 
part  of  the  stricture,  and  then  connected  with  the  negative  pole  of  the 
electrogalvanic  machine,  the  positive  pole  being  placed  in  the  hand 
or  elsewhere.  The  application  should  be  made  daily,  using  each  time  a 
larger  instrument,  and  allowing  the  current  to  flow  from  ten  to  twenty 
minutes,  according  to  the  feelings  of  the  patient.  Eight  or  ten  applica- 
tions have  usually  proved  sufficient." 

Daily  applications  are,  of  course,  entirely  too  frequent  and  much 
of  the  early  condemnation  of  this  method  may  have  originated  in  this 
error. 

His  later  statement,  moreover,  that  electricity  is  of  service  in  old 
neglected  cases  with  thick,  gristly,  cartilaginous  mass  is  an  error.  It 
is  noticed  that  he  correctly  emphasized  the  application  of  the  negative 

*  Application  and  Effect  of  Electricity  and  Gulvani.sia  in  the  Treatment  of  Cancerous, 
Nen'ous,  Rheumatic  and  other  Affections. 


NONOPERATIVE  TREATMENT  OF  STRICTURE  385 

galvanic  pole  to  the  lesion.  Later,  in  1889,  W.  IT.  White^  who  is  still 
looked  on  as  an  authority,  makes  the  following  misstatement  concerning 
strictures  of  the  urethra  and  of  the  Eustachian  tube.  "'Jliese  have 
been  treated  by  passing  an  appropriate  catheter  insulated  except  at 
its  point.  This  is  connected  with  the  anode.  The  kathode  is  on  some 
indifferent  spot,  and  a  galvanic  current  of  five  milliamperes  is  allowed 
to  flow  for  five  minutes.  We  have  not  yet  sufficient  evidence  before 
us  to  show  whether  this  treatment  is  of  any  value,  for  while  many 
observers  extol  it,  others  say  that  any  good  that  may  result  is  transi- 
tory." It  is  the  kathode  or  negative  and  not  the  anode  or  positive 
which  should  be  applied. 

In  1888,  Brown  ^  aims  to  show  conclusively  that  electricity  applied 
to  stricture  results  in  many  instances  in  additional  fibrosis,  and  that  it  is 
not  only  without  benefit  but  often  injurious.  Taylor'*  in  1904,  reiterates 
this  position  by  stating:  "Now,  electrolysis  has  not  an  electroaffinity 
for  the  stricture-tissue,  leaving  the  mucous  membrane  unaffected,  but, 
on  the  contrary,  acts  upon  this  membrane  and  destroys  it;  and  when- 
ever the  mucous  membrane  lining  in  a  stricture  is  destroyed  there  is  a 
grave  probability  that  the  urethra  will  be  obliterated."  He  then  goes 
on  to  describe  Fort's  electrolyser,  which  is  in  fact,  a  galvanocautery  of 
very  mild  type,  and  employs  a  current  at  least  twice  as  strong  as  that 
advised  by  modern  procedures. 

The  error  then  of  most  of  these  adverse  critics  was  either  in  using 
the  positive  galvanic  pole  or  anode  instead  of  the  negative  galvanic 
pole  or  kathode  upon  the  stricture,  or  in  undue  strength,  duration  and 
frequency  of  application,  or  in  haste  for  penetration.  If  tissue  sub- 
stance comes  away  on  the  surface  of  the  instrument  the  positive  pole 
has  been  used.  As  in  dilatation,  so  in  electrolysis,  gentleness,  patience, 
and  deliberation  should  be  employed  and  the  latter  method  should 
not  be  numbered  among  the  disapproved  methods,  but  rather  among 
the  approved  procedures  for  the  properly  chosen  case. 

Selection  of  Case. — Galvanism  or  any  other  form  of  electricity  will 
not  remove  dense  scan  tissue  and  much  of  the  adverse  criticism  of 
electrical  treatment  of  stricture  is  founded  on  error  in  selection  of  the 
case  and  on  improper  adaptation  of  the  method.  Galvanism  is  advis- 
able only  in  open  and  close  strictures  which  are  safely  passable  without 
filiform  guides,  but  when  tortuosity  and  dense  infiltration  are  present 
other  methods  are  preferred.  Where  dilatation  is  painful  galvanic 
electrolysis  may  be  substituted  with  equally  good  results  and  without 
the  pain,  and  where  there  is  a  tendency  toward  spasm  and  great 
irritation,  the  new  current  of  d'Arsonval  is  advisable.  The  galvanic 
negative  pole  only  must  be  applied  to  the  strictm-e,  as  a  rule  preferably 
with  a  silver  or  zmc  electrode  and  the  positive  pole,  instead  of  being 
the  usual  small  sponge  contact,  an  inch  or  two  in  diameter,  should  be 

1  A  Text-book  on  General  Therapeutics,  p.  292. 
^  Jour,  of  Cutan.  and  Genito-urinary  Diseases,  1888,  vi,  244. 

3  A  Practical  Treatise  on  Genito-urinary  and  Venereal  Diseases  and  SjT)hilis,  3d  ed. , 
p.  217. 

25 


386  TREATMENT  OF  STRICTUliE  OF  THE  VHETIIRA 

nearly  a  square  fot^t,  in  area  twelve  by  eight  inches,  well  moistened  with 
warm  water  anil  held  apiinst  the  abdomen  by  a  soft  bau"  of  jii'avel  so 
as  to  insure  com])lete  contact  of  it  as  the  indilTerent  electrode. 

Instruments  and  Supplies  must  include  a  reliable  source  of  jjahanism 
or  d'Arsonval  current,  from  either  battery  or  wall  machine  connected 
with  the  street  current,  with  suitable  controls  and  a  reliable  milli- 
amperemeter  in  circuit  with  the  ])atient  and  cables,  a  larue  pad  elec- 
trode twelve  by  eifjht  inches,  a  soft  sandbag,  assortment  of  insulated 
electrodes  in  the  form  of  bougies-a-boule,  straight  and  curved  sounds, 
and  the  like,  a  urethrosco])ic  outfit  of  tubes,  ajiplicators  and  soluti(His, 
such  as  tincture  of  iodin,  nitrate  of  silver,  chlorid  of  zinc  in  1,  o,  10, 
25  and  50  per  cent,  watery  solution,  aromatic  suli)huric  acid  and  their 
type.  Local  anesthetics  are,  as  a  rule,  unnecessary  but  may  be  included 
in  this  list  if  desired  and  applied  either  directly  to  the  part  or  by 
injection  with  a  syringe,  and  none  is  better  than  5  per  cent,  alypin  in 
borogl>"ceride  or  Irisli  moss  jelly,  which  will  serve  as  lubricant  also. 

Technic  of  Galvanic  Electrolysis. — In  type  gahanism  is  bipolar. 
The  patient  is  placed  on  a  urological  table  covered  with  insulating 
cushions  on  his  back,  in  position  exactly  as  for  dilatation,  and  the  large 
indifferent  positi^•e  electrode  is  moistened  with  warm  water  and  com- 
fortably fitted  to  the  abdomen  under  the  bag  of  gravel  and  then  con- 
nected with  the  positiAC  pole  of  the  galvanic  apparatus.  The  negative 
electrode  also  connected  is  passed,  dow^n  to  the  face  of  the  stricture 
if  a  bougie-a-boule,  or  just  through  the  stricture  if  a  sound,  so  that  the 
band  is  felt  to  lie  o\-er  the  metal  tip.  The  current  is  now  tiu'ned  on  in 
strength  of  from  three  to  fi^•e  milliami)eres,  but  no  more,  and  is  allowed 
to  remain  on  for  from  three  to  eight  minutes  but  no  longer.  As  a  rule, 
the  bougie-a-boule  or  sound  which  previously  had  hesitated  to  pass 
will  within  this  interval  slip  painlessly  by  the  band  and  may  then  be 
withdrawn,  and  ob\iously  that  size  of  electrode  must  be  selected 
which  might  be  used  as  a  dilator  if  the  latter  were  the  intended  method 
for  the  given  case.  In  other  words,  it  should  not  be  expected  that  an 
instrument  many  sizes  larger  than  the  known  caliber  of  the  stricture 
may  wisely  be  passed  by  electrolysis  any  more  than  by  dilatation. 
After  the  instrument  has  glided  through  the  stricture  the  current 
should  be  turned  off  before  withdrawal,  otherwise  irritation  of  the 
canal  may  ensue  by  having  the  current  on  as  the  instrinnent  passes 
out  of  the  canal. 

The  repetition  of  treatment  is  about  the  same  as  that  for  dilatation 
determmed  largely  by  the  behavior  of  the  stricture: — not  oftener  than 
once  in  three,  seven  or  ten  days,  so  that  the  mucosa  will  have  abundant 
opportimity  to  gain  by  each  treatment  and  not  to  be  irritated  by  undue 
frequency  and  activity  of  application. 

Newman,^  in  1S90,  has  prol)ably  ])roduced  the  most  careful  paper 
on  this  subject,  from  which  the  following  essentials  are  adapted  by 
abbreviation  of  his  "  Recapitulation  of  Rules:"  A  good  battery  or  other 

1  Twenty  Years'  Retrospect  in  the  Treatment  of  Urethral  Strictures  by  Electrolysis, 
with  Demonstrations. 


NONOPERATIVK  TREATMENT  OF  ^STRICTURE  387 

constant  source  of  ciUTcnt,  a  siiita})lc  rnillianijK'rcrnctcr,  a  larjfe  posi- 
tive indifferent  pole  electrode,  a  selection  of  the  four  varieties  of  nega- 
tive electrode,  preferably  with  short  curves,  immersion  of  the  battery 
plates  in  the  electrofluid  before  turning  on  the  current  which  must 
begin  and  end  at  zero,  kjiowledge  of  the  susceptibih'ty  f)f  the  patient 
to  the  current,  weak  currents,  of  from  2^  to  5  milliarn})eres  as  extremes 
and  regulated  to  the  work  done,  long  intervals  at  least  a  week,  applica- 
tions for  from  five  to  twenty  minutes,  recumbent  posture,  no  anesthetics, 
no  force,  no  hemorrhage,  never  two  electrodes  in  succession  at  one 
treatment,  no  pain  during  treatment,  and  no  treatment  during  acute 
and  subacute  inflammation,  no  nonconducting  lubricants,  and  by 
choice  bougies  three  sizes  larger  than  the  caliber  of  the  stricture. 

Technic  of  d'Arsonval  Electrolysis. — This  current  is  a  unipolar,  and 
it  is  chosen  for  strictures  accompanied  by  much  pain  and  spasm  in 
which  the  element  of  relaxation  becomes  important.  The  patient  lies 
on  a  d'Arsonval  couch,  or  autocondensation  couch,  in  the  dorsal 
position,  and  the  source  of  the  current  is  a  special  high-frequency 
machine  from  which  the  d'Arsonval  current  may  be  derived,  which  is 
of  alternating  type.  The  strength  of  current  is  on  an  average  100 
milliamperes  for  strictures  in  general.  The  size  of  the  electrode  should 
be,  as  in  galvanic  electrolysis,  not  more  than  two  or  three  sizes  of  the 
French  scale  larger  than  the  caliber  of  the  stricture  and,  as  in  the  latter 
electrical  treatment,  the  application  is  made  until  yielding  appears, 
but  without  traumatism,  bleeding,  pain  or  cauterization  in  even 
small  degree  and  without  the  presence  of  acute  or  subacute  inflamma- 
tion. The  insulation  of  the  electrodes  must  be  very  heavy  otherwise 
this  high  tension-current  will  short  circuit  and  no  good  come.  It  is 
well  to  have  a  set  of  instruments  properly  insulated  for  the  d'Arsonval 
treatment  and  to  employ  this  same  set  for  the  gah'anic  current  as 
occasion  may  arise. 

Thiosinamine  in  10  per  cent,  solution  and  in  15  minim  doses  has  been 
recommended,  hypodermatically  administered  at  each  visit  in  associa- 
tion with  the  electrolysis,  or  fibrolysin  which  is  salicylate  of  thiosina- 
mine, may  be  used  in  the  same  manner.  Both  are  regarded  as  aids  in 
the  absorption  of  newly  formed  fibrous  tissue,  but  not  of  hard  scar 
tissue. 

Aftertreatment  of  Electrolysis  of  Stricture. — Immediate  further  atten- 
tion is  so  far  as  dressing  is  concerned  nothing,  but  it  is  well  to  combine 
with  each  application  urethroscopic  treatment  of  the  zone  behmd  the 
stricture,  exactly  as  has  been  recommended  in  dilatation.  That  is  to 
say,  as  soon  as  the  lumen  of  the  stricture  is  sufficiently  open  to  permit 
these  applications  they  should  be  begun  and  that  solution  chosen 
which  seems  best  for  the  condition  displayed.  lodin  is  a  good  antiseptic, 
silver  and  zinc  are  stimulating,  astrmgent,  antiseptic  and  with  judg- 
ment mildly  caustic,  and  aromatic  sulphuric  acid  seems  particularly 
helpful  to  suppurating  mucosa.  Urinary  antiseptics  may  wisely  be 
administered  during  the  active  course,  and  later  during  each  instrmnen- 
tation, 


3S8  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

Remote  Aftertreatment. Tho  final  treatment  is  exactly  that  for  dila- 
tatit)n  and  consists  in  the  passing  of  sounds  from  one  to  several  times 
each  year  as  insurance  against  relapse.  The  end-result  is  that  of 
dilatation  with  the  added  advantage  that  in  painful  irritable  lesions 
which  might  require  incision  and  l)cd  care  this  more  conservative 
plan  may  be  followed  Avith  the  gam  of  painlessness  and  safety  and 
of  the  added  destruction  of  organisms  within  the  tissue  ])y  the  current 
itself  throughout  the  treatment. 


OPERATIVE  TREATMENT  OF  STRICTURE. 

Approved  Procedures. 

Ap])r()ve(l  ])rocedures  liaAC  already  been  stated  as  dilating  ure- 
throtomy, internal  urethrotomy,  combined  external  and  internal  ure- 
throtomy and  excision,  wliile  the  disa])])r{)ved  o])erations  have  been 
both  mentioned  and  dismissed  with  the  basis  of  their  condemnation  on 
page  363.  The  general  application  of  operative  treatment  compared 
with  nonoperative  measures  has  also  already  been  sufficiently  detailed 
on  page  363. 

Internal  Urethrotomy. 

Varieties. — There  are  two  classes  of  operation :  those  of  the  meatus, 
called  meatotomy,  and  -those  of  the  anterior  and  posterior  urethra, 
called  internal  urethrotomy,  without  distinction  as  to  the  point  of  the 
canal  involved. 

Meatotomy. 

Instruments  and  Supplies  include  a  hyperdermatic  syringe,  cocain  or 
other  local  anesthetic  solution,  blunt-point,  straight-blade  bistoury, 
l)ougies-a-})oule,  e\en  numbers  24-34  F.,  and  straight  sounds,  even 
sizes  24  to  34  Fr.,  cotton,  gauze,  scissors  and  probe.  The  anesthesia 
is  local  and  produced  either  by  injecting  weak  cocain  solution  hito  the 
site  of  the  incision,  or  by  inserting  a  wick  of  gauze  or  cotton  with  the 
probe  into  the  meatus  for  an  inch,  and  then  impregnating  this  with 
the  anesthetic  solution  and  allowing  it  to  remain  five  or  ten  minutes. 
The  incision  is  in  the  midline  along  the  floor  in  the  normal  meatus,  and 
along  the  roof  also  when  there  is  anatomical  defect  in  the  form  of 
reduplication  of  the  canal,  w'hich  may  be  a  dimple,  a  blind  pDUch  or  a 
canal  or  a  diaphragm  and  must  be  explored  by  the  probe  for  its  limit 
before  operation.  I'he  dej)th  of  the  incision  enlarges  the  meatus  up  to 
28  to  34  Fr.  according  to  the  diameter  of  the  urethra  in  the  proximal 
canal,  determined  with  the  bougie-a-boule  after  the  preliminary  open- 
ing of  the  stricture.  It  should  be  about  two  sizes  larger  than  the  final 
diameter  required  because  contraction  always  occurs  to  about  this 
limit  and  it  should  never  be  extended  to  involve  the  floor  of  the  urethra 
through  the  skin,  as  one  occasionally  sees,  constituting  a  veritable 
postoperative  balanic  hypospadias.    The  extent  of  the  incision  along 


OPERATIVE  TREATMENT  OF  STRICTURE 


389 


the  urethra  must  reheve  the  constriction  at  the  meatus  and  at  the 
proximal  limit  of  the  fossa  navicularis  whose  <liamct('r  usually  dupli- 
cates that  of  the  meatus. 

The  sounds  are  of  value  in  this  determination,  })ecause  sometimes  a 
bougie-a-boule  will  seem  to  show  a  constriction  where  none  exists  to 
the  sound  and  it  is  well  to  use  both  to  recognize  a  narrowing  back  of 
the  fossa  navicularis  before  proceeding  with  definite  extension  of  the 
incision  through  it. 

The  dressing  is  conveniently  a  small  strip  of  the  selvage  edge  of 
gauze  free  from  ravel,  tucked  into  the  depth  of  the  wound  with  the 
probe  and  kept  in  place  by  cutting  it  off  quite  close  to  the  glans  and  by 


Fig.  110. — Supplies  for  meatotomJ^  From  left  to  right  are  shown  local  anesthetic 
and  syringe^  blunt-point,  straight-blade  bistoury,  metal  bougie-a-boule,  straight  sound, 
cotton  and  gauze  swabs,  forceps,  probe,  selvage-edge  gauze  drain  and  scissors. 


directing  the  patient  to  seize  the  meatus  from  below  while  urmatmg. 
Thymol  iodid  or  bismuth  subgallate  powder  may  be  sprinkled  upon 
wound  and  gauze  before  this  dressing,  a  loose  external  gauze  dressing 
prevents  any  ooze  of  blood  from  soiling  the  underclothing  and  after  a 
half  hour's  rest  for  cessation  of  hemorrhage  the  patient  goes  home. 
The  aftertreatment  is  comprised  of  renewals  of  the  gauze,  the  first 
strip  of  which  usually  comes  away  on  the  third  daj^  and  of  the  passing 
of  sounds  up  to  a  nimiber  or  two  less  than  the  size  of  the  original  cut 
in  order  to  prevent  the  wound  from  collapsing  and  healmg,  and  to 
compel  it  to  cover  in  from  the  sides  with  epithelium.  The  end  result  is  a 
canal  of  nearly  uniform  diameter  from  the  penoscrotal  juncture  for- 


300  TREAT^rEXT  OF  >iTR[CTVRE  OF  THE  rRETIIRA 

ward,  so  that  tlie  treatment  of  the  deeper  canal  may  proceed  with 
convenience  and  thoroutrlmess.  Tlie  patient  shonld  be  informed  that 
his  stream  will  he  rihhonlike  and  possibly  spatterin<?,  through  the  free 
outlet. 

Internal  Urethrotomy. 

Synonym  and  Definition.      Internal  incision  of  tlie  urethra. 

Instruments  and  Supplies  should  include  those  for  meatotomy,  as 
this  is  almost  always  necessary,  and  add  the  followiiio:  one  cone  i)oint 
lU'ethral  syringe,  5  per  cent,  alypin  or  other  local  anesthetic  in  boro- 
glyeerid  or  Irish  moss  jelly,  lubricants  of  the  same  substances,  ball 
sounds  and  standard  sounds  even  sizes  up  to  32  Fr.,  Otis  urethro- 
tome with  straight  and  curved  tunneled  points,  curved  and  straight 
Maisonneuve  urethrotome  with  the  three  knives  of  the  author  cutting 
to  22,  20  and  30  Fr.  diameter,  filiform  guides,  lu'ethroscope  with  lamp 
and  knife,  assortment  of  catheters,  bladder  syriftge  150  c.c.  capacity, 
weak  sih'er  nitrate  or  other  antiseptic  solutions  and  applicators,  card- 
board splints,  adhesive  plaster,  sterile  cotton  and  gauze  dressings  and 
gan/e  bandages. 

Type  of  Case. — The  operation  is  applicable  for  close  strictures  which 
admit  the  Otis  urethrotome  (16  Fr.  diameter)  or  the  stafl'  of  the 
Maisonneuve  urethrotome  (7  Fr.  diameter).  Simj^le  threadlike 
transverse  strictures  may  be  located  with  and  divided  through  the 
urethroscope  tube. 

Preparation  of  Patient  and  Preliminaries  are  the  same  as  for  any  other 
urethral  operation,  i\nd  the  anesthesia  may  be  local  in  moderate  cases 
with  one  or  two  strictures,  or  general  in  marked  cases  requiring  deep 
extensive  incision  of  one  or  more  dense  strictures.  A  preliminary 
meatotomy  is  in  most  cases  advisable  in  order  to  permit  proper  cali- 
bration of  the  lu-ethra  during  the  procedure.  The  site  of  internal 
urethrotomy  is  always  dorsal  in  the  midline,  in  depth  dividing  all  the 
bands  of  the  stricture,  and  in  extent  interesting  the  infiltrated  zones 
distal  and  proximal  to  the  contraction,  so  as  to  relieve  tendency  to 
relapse  from  these  annexa.  The  localization  and  calibration  of  the 
strictures  is  done  with  the  ball  sound,  beginning  with  the  largest,  which 
will  pass  the  distal  urethra  easily  with  or  without  the  meatotomy,  and 
which  will  thus  lodge  on  the  face  of  the  first  stricture.  The  ])enis  is  now 
allowed  to  resume  semifiaccid  state  and  the  distance  of  this  stricture 
from  the  meatus  is  laid  off  on  the  measure  and  recorded.  Each  stricture 
proximal  to  the  first  is  measured  in  the  same  manner  and  all  the  dis- 
tances are  recorded  on  the  shaft  of  the  Otis  urethrotome  by  placing  an 
elastic  band  for  each  stricture  at  the  required  points,  starting  with  the 
full  exposure  of  the  knife  and  allowing  a  half-inch  in  addition  for 
division  of  the  proximal  annexa.  The  more  modern  urethrotomes  have 
inch-  and  half-inch  subdivisions  on  the  shaft  for  this  purpose,  while 
the  Maisonneuve  shaft  requires  neither  elastic  nor  scale  because  the 
division  of  the  stricture  by  this  methorl  is  from  before  backward  and 
thus  strictlv  localized  to  the  cicatrix. 


OPERATIVE  TREAT  ME  MT  OF  HTIiTCTUliE 


•.V.)\ 


Varieties. — Anterior  and  posterior  internal  urethrotomy  by  the 
metliods  of  Otis  and  Maisonneuve  and  tlie  urethroscope  are  recognized. 
Dilating  urethrotomy  is  a  variety  of  the  standard  operation  in  which 
the  element  of  tension  or  dilation  of  the;  mucosa  is  largely  exaggerated 
until  divulsion  is  present.  'J'his  introduces  all  the  objections  of  rapid 
dilatation  or  divulsion  of  stricture  and  for  this  reason  this  step  is  no 
longer  approved.    With  its  omission  dilating  urethrotomy  is  synony- 


FiG.  111. — Supplies  for  internal  urethrotomy  and  uretliroscopic  internal  urethrotomy. 
From  left  to  right  are  shown  for  internal  urethrotomy  syringe  and  anesthetic  with 
catheter  for  filling  the  bladder  and  urethra,  author's  model  of  curved  and  straight 
Maisonneuve  urethrotome  with  knife,  Otis  urethrotome  with  knife,  metal  bougie-a-boiile, 
straight  sound,  author's  irrigating  curved  sound,  whalebone  filiform  guide,  and  Janet- 
Frank  syringe.  For  urethroscopic  internal  urethrotomy,  the  Chetwood  urethroscope 
and  lamp  and  long,  sharp-pointed  knife  are  to  the  left  of  the  Janet-Frank  sj-ringe. 


mous  with  the  method  involved  in  the  use  of  the  Otis  urethrotome,  to 
be  described  below,  which  aims  to  divide  all  the  bands  of  the  stricture. 
Anterior  Internal  Urethrotomy. — Otis's  Internal  Urethrotomy, —  Type 
of  Case. — The  Otis  Internal  urethrotomy  is  available  for  anterior  and 
posterior  cases  with  preference  for  the  former,  as  complications  so  often 
occur  with  the  posterior  strictures.  The  technic  of  passmg  the  shaft 
for  anterior  urethrotomy  is  exactly  that  of  the  straight  sound  and  the 


392 


TREATMENT  OF  STRICTURE  OF  THE  URETHRA 


groove  of  the  knife  is  held  strictly  in  the  middle  line  of  the  penis  wliich 
is  allowed  to  assume  the  semiflaccid  position  as  soon  as  the  point  of 
the  distal  stricture  is  reached.  The  dilating  jaw  is  now  opened  until 
the  dial  indicates  about  two  sizes  larger  than  that  shown  hy  the  largest 


Fig.  112. — Author's  Maisonneuve  iustniineiit.  Straight  and  cuivcil  staffs  (.1-5), 
with  olive  tunneled  tips  carrying  24  inch  whalebone  filiform  guides,  which  pass  backward 
through  a  canal  in  a  long-lever  handle,  which  being  opposite  the  groove  protects  the 
fingers  from  accidental  wounds.     C,  D,  E,  are  30,  26  and  24  French  knives. 


bougie-a-boule  accepted  by  the  distal  urethra  which  usually  places 
under  full  tension  all  the  stricture  bands,  which  are  then  divided  by 
pulling  the  knife  forward  from  an  inch  to  an  inch  and  a  half  and 
retiring  it  to  its  socket.  The  second  and  subsequent  strictures  are 
divided  in  exactly  the  same  procedure,  removing  each  elastic  band 


OPERATIVE  TREATMENT  OF  STUJCTfJRE  393 

with  the  progress  made  until  finally  all  have  been  dividcfi.  Sounds 
are  now  passed  to  establish  the  full  lumen  of  the  urethra  into  th(; 
bladder  and,  as  in  meatotomy,  about  two  sizes  h,r^vs  than  the;  enrl  result 
desired  in  allowance  for  contracture.  I3ougies-a-boule  are  also  used  to 
detect  undivided  bands  which  would  indicate  measurement  of  their 
position  and  division  by  the  same  method. 

Maisonneuve's  Internal  Urethrotomy. —  Type  of  Case. — I'he  Maison- 
neuve  internal  urethrotomy  is  applica})le  for  anterior  and  posterior 
strictures  with  the  same  warning  of  danger  in  deep-seated  lesions.  The 
filiform  guide  must  be  passed  and  the  shaft  of  the  instrument  threaded 
over  this  by  the  technic  described  for  the  dilatation  of  stricture  with 
tunneled  and  grooved  sounds.  The  modern  instrument  has  the  tunnel 
opposite  the  groove  of  the  knife  so  that  as  far  as  possible  the  filiform 
will  not  be  cut.  With  the  penis  on  the  stretch  and  the  groove  in  the 
middle  line,  the  knife  is  entered  and  slid  very  slowly  down  the  urethra 
so  as  not  to  fold  and  cut  the  mucosa  before  the  stricture  is  encountered, 
which  is  divided  by  steady  pushing  of  the  blade  through  the  mass. 
Each  stricture  is  treated  in  the  same  manner  as  reached  until  all  have 
been  divided.  The  author  adopts  three  blades,  22,  26  and  30  Fr.  on 
the  basis  that  the  average  membranous  urethra  is  27  Fr.,  and  is  advis- 
edly not  artificially  increased  in  size.  If  anterior  urethrotomy  alone  is 
desired  the  shaft  of  the  instrument  is  held  vertical  to  the  table  and  the 
knife  passed  until  the  base  of  the  curve  is  reached,  which  in  this  posi- 
tion will  ordinarily  be  in  the  deep  urethra  but  not  the  bladder.  If  a 
posterior  urethrotomy  is  also  required,  the  blade  is  advanced  until 
stopped  by  the  groove  in  the  instrument  which  is  usually  just  outside 
the  sphincter  of  the  bladder  which  should  in  no  case  be  divided.  Hav- 
ing incised  all  the  strictures  with  the  proper  size  of  blade  selected  in 
accordance  with  the  measurements  with  the  bougie-a-boule,  the  knife 
is  slowly  withdrawn  and  followed  by  the  shaft  and  filiform.  "Sawing 
back  and  forth"  with  the  knife  is  prohibited  by  respect  for  the  mucosa, 
but  is  sometimes  seen  in  the  hands  of  general  surgeons.  The  passmg 
of  sounds  and  bougies-a-boule  is  the  next  step  exactly  as  in  the  Otis 
method. 

Posterior  Internal  Urethrotomy. — Limitations  and  Dangers. — Pos- 
terior internal  urethrotomy  is  undertaken  with  caution  on  account  of 
the  frequency  of  infection  and  complications  in  these  lesions,  the  diffi- 
culty of  drainage,  and  the  facility  and  rapidity  of  absorption. 

The  presence  of  the  filiform  guide  is  essential  and  the  ^Nlaisonneuve 
is  preferable  to  the  Otis  method  because  its  shaft  duplicates  the  form 
of  the  standard  sound  and  is^more  manageable  than  that  of  the  Otis 
instrument  in  the  deep  urethra,  which  has  the  difficulties  of  all  straight 
instruments  in  this  region.  In  all  severe  strictures  of  the  posterior 
urethra  therefore  only  the  external  urethrotomy  is  mdicated  and 
advisable. 

Urethroscopic  Internal  Urethrotomy. — Selection  of  Case  assigns  this 
method  only  to  threadlike  strictures  of  the  anterior  urethra  more  or 
less  transversely  placed. 


394  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

Instruments  and  Supplies  ;m1(1  to  those  of  the  foregomg  procedures  only 
;i  set  of  oi)en-eii(l  urethrosc'oi)es  of  the  Chetwooil  ty])e,  hnn])s,  source 
of  ilhiiniiijition  and  its  control,  and  an  assortment  of  urethroscopic 
knives  and  applicatoi-s,  if  the  incision  method  is  adopted,  and  the 
Buerger  operation  urethrocystoscope,  high-frequency  cable,  and  high- 
frequency  transformer  and  switchboard  if  the  fulguration  method  is 
preferred.  The  ])rei)aration  of  tlie  ])atient  is  that  for  any  standard 
urethral  ]ir(H'edure  and  the  anesthesia  is  almost  invariably  local. 

Technic  by  Incision  places  the  patient  in  the  moderate  lithotomy 
posture  and  the  lU'ethroscope  is  passed  in  the  standard  maimer  down 
to  the  face  of  the  stricture  whose  caliber  has  ])reviously  been  carefully 
measured,  using  a  tube  if  i)ossible  which  will  not  ])ass  the  band  so  that 
the  latter  is  stretched  across  the  lumen.  The  knife  is  now  taken  and 
the  band  divided  by  transfixion,  from  base  to  free  border,  and  then 
sounds  are  passed  in  order  to  ojicn  this  little  cut  to  the  full  diameter 
of  the  canal.  The  disachantages  are  uncertainty  as  to  di^•ision  of  all 
the  fibers  of  both  stricture  and  its  annexa  and  consequent  likeliliood  of 
relapse. 

Technic  by  High-frequency  Current  of  Oudin. — This  imolves  the  same 
preliminaries  ijut  includes  ]jassage  of  the  o])eration  urethrocystoscope 
through  the  stricture  and  withdrawal  until  the  band  crosses  the  fiekl 
near  the  point  of  the  cable,  which  is  advanced  until  it  touches  the 
obstruction  near  the  base.  The  current  is  now  turned  on  with  a  spark 
gap  of  I  to  J  inch,  and  the  switch  half-open  on  the  controller  and  applied 
until  the  mucous  membrane  is  thoroughly  blanched  of  all  circulation. 
The  point  of  ajjplication  is  now  mo\'ed  outward  luitil  from  base  to 
border  the  band  is  cauterized  throughout  its  depth.  Sounds  are  noW 
passed  in  order  to  spread  open  the  cauterized  zone  thus  produced  in 
the  stricture  and  thereby  to  remove  all  obstruction.  Small  bands  may 
be  wholly  removed  by  this  procedure.  The  disadvantages  of  this 
method  are  likeliliood  of  cauterizing  beyond  the  base  of  the  stricture 
into  the  urethral  wall  and  producing  a  more  extensive  infiltration  than 
the  stricture  itself.  With  caution  and  judgment  it  is  an  almost  painless 
highly  efficient  procedure  and  not  followed  by  hemorrhage. 

Aftertreatment  of  Internal  Urethrotomy.  —  hnmedlate  methods  must 
conij)rise  flushing  of  the  urethra  with  the  soft  catheter  and  syringe 
and  1  in  2000  silver  nitrate  solutions  at  105  to  110°  F.  which  may  also 
be  used  in  the  bladder  if  it  has  been  entered,  as  a  means  of  asepsis  and 
hemostasis.  The  dressing  is  with  cardboard  splints  and  adhesive 
plaster  with  pressure  sufficient  to  stop  bleeding  but  insufficient  to 
obstruct  urination  or  circulation,  as  either  or  both  will  induce  conges- 
tion, edema  and  secondary  hemorrhage.  The  raeatotomy,  if  performed, 
is  dressed  as  just  described.  The  remote  aftertreatment  is  the  matter 
of  passing  sounds  exactly  as  noted  under  dilatation  and  throughout 
the  aftertreatment  urinary  antiseptics  hkd  best  be  administered  for  a 
brief  period  in  association  with  each  instrumentation,  and  especially 
while  in  bed  just  after  the  operation. 

The  immediate  aftertreatment  of  both  the  incision  and  fulguration 


OPERATIVE  TREATMENT  OF  STRICTURE 


395 


methods  with  the  urctliroscopc  is  a})()iit  the  same  as  that  for  meatotomy 
and  iiitenial  uretlirotoiny,  and  consists  of  the  passing'  of  sounds  in 
order  to  make  the  divided  mucosa  close  in  from  the  sides  with  epithe- 
lium as  a  new  surface,  leaving  the  band  divided  into  two  little  tabs 
which  do  not  obstruct  and  usually  atrophy  as  the  end  result  in  many 
cases.  The  same  rule  for  the  remote  aftertreatment  of  all  stricture 
cases  applies  and  requires  the  passing  of  sounds  every  few  months 
as  preventive  of  relapse. 


Fig.  113. — Instruments  for  external  urethrotomy  with  a  guide.  From  above  down- 
ward at  the  top  are  the  standard  perineal  tube  and  elbow  catheter  for  drainage  and  irri- 
gation; the  author's  standard  double  taper  irrigating  sound  with  obturator  in  situ; 
and  at  the  bottom  the  author's  standard  tunneled  and  grooved  sound  -n-ith  obturator 
in  the  canal  and  with  a  long  whalebone  filiform  guide  through  the  tunnel  and  a  sharp 
point  and  a  blunt  point  small  retractor.  From  left  to  right  in  the  middle  of  the  figure 
are  scalpel,  sharp  and  blunt  point  straight  blade  bistouries,  arterj-  clamp,  scissors  curved 
on  the  flat,  ligature,  long  forceps,  needle  holder,  assorted  needles  with  a  suture  in  one 
needle  and  a  curve  grooved  director. 


External  Urethrotomy. 

Synonyms. — Perineal  section,  perineal  cystotomy,  combmed  internal 
and  external  urethrotomy  and  urethrotomy  with  dramage. 

Selection  of  Case. — In  addition  to  the  principles  m  the  early  part 
of  this  chapter  for  the  choice  of  the.  various  treatments  of  stricture  the 
following  details  apply  for  this  operation.  External  urethrotomy  is 
available  for  stricture  impassable  or  passable  only  to  filiform,  or  so 


396  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

dense,  tortuous  and  complicated  as  to  render  dilatation  impossible 
and  internal  urethrotomy  inadvisable  tln-ouirli  absence  of  drainajie. 
It  is  also  the  one  operation  for  the  com])Jieati()ns  and  secpiels  of  stric- 
ture, sudi  as  posterior  chronic  urethritis,  })rostatitis,  abscess,  fistula, 
false  passage,  mpture  of  the  urethra  by  external  direct  \iolence  or  by 
internal  nuiscular  strain  to  overcome  the  stricture  and  the  sequel  of 
rni>turc'  -  extravasation  of  blood  and  urine. 

Varieties. — The  varieties  are  two:  (1)  external  urctln-otoniy  with  a 
guide,  and  (2)  external  urethrotomy  without  a  guide,  obviously  in 
accordance  with  whether  or  not  a  guide  of  any  description  may  be 
passed  through  the  stricture,  usually  and  formerly  from  the  meatus 
backward,  less  connnoidy  and  lately  either  in  this  direction  or  from 
the  bladder  forward,  as  in  Sinclair's  method. 

Instruments  and  Supplies  include  all  those  recommended  for  internal 
urethrotomy,  as  this  oj^eration  is  almost  invariably  an  essential  pre- 
Uminary  to  the  external  uretin-otomy  and  add: — tunneled  and  grooved 
irrigating  sounds,  tunneled  urethral  stall's,  two  scalpels,  short  and  long 
blade,  one  blunt-point,  straight-blade  bistoury,  forceps,  artery  clamps 
and  catgut,  assorted  rubber  or  lisle-thread  catheters,  one  silver  female 
catheter,  one  catheter  staff,  one  director  with  six-inch  blade,  perineal 
tubes  20,  28  and  30  Fr.,  one  100  c.c.  hand  syringe,  sty])tic  powder, 
boric  acid  powder,  needle  holder,  needles,  silkworm  gut,  sterilized 
iodoform  and  plain  gauze,  T-binder,  safety  pins,  glass  connecting 
luiks,  rubber  tubing  and  one  quart-bottle  for  collection  of  urine. 

General  Preliminaries  and  Preparation  of  Patient  are  those  standard 
for  any  major  urological  operation,  and  must  include  careful  emptying 
of  the  rectum  for  unobstructed  deep  field.  The  anesthesia  may  be 
local,  first  by  filling  the  anterior  lu-ethra  with  alypin  5  per  cent,  in  Irish 
moss  or  boroglycerid  for  ten  minutes,  and  second  by  infiltration  of 
the  skin  and  perineal  tissues  down  to  the  stricture  substance  with 
cocain  solution,  1  grain  in  1  ounce  (1  in  500).  The  infiltration  must  be 
continued  into  the  stricture  substance  when  the  deep  field  is  fully 
exposed.  In  the  average  case,  general  anesthesia  is  to  be  preferred, 
and,  at  times,  all  anesthesia  is  omitted  when  the  kidneys  are  compro- 
mised and  uremia  hnminent  or  present.  In  these  latter  circumstances 
the  operation  is  one  of  no  small  hazard.  The  posture  is  exaggerated 
lithotomy. 

External  "Qrethrotomy  with  a  Guide. — Varieties. — The  varieties  are 
two  ill  accordance  with  whether  a  metal  staff"  or  only  the  whalebone 
filiform  guide  nia\'  be  i)assed  through  the  stricture. 

External  Urethrotomy  with  a  Metal  Staff. — Preliminaries.—  Just  as 
in  internal  urethrotomy  a  prelimii:ary  meatotomy  is  necessary  so  in 
external  urethrotomy  a  preliminary  internal  urethrotomy  is  almost 
always  required  in  the  method  just  fully  outlined. 

Technic. — As  for  external  urethrotomy  itself,  the  filiform  guide  is 
introduced  and  the  tunneled  and  grooved  irrigating  sound  of  the 
author  or  a  tunneled  staff'  is  threaded  upon  it  and  passed  into  the 
bladder  by  the  exact  procedure  laid  down  for  the  passage  of  sounds 


OPERATIVE  TREATMENT  OF  STRICTURE  397 

thr()ii<i;li  tight  strictures,  or  if  the  stricture  will  acc(;])t  the  staff  without 
the  whalebone  guide  it  is  entered  in  the  method  detailed  for  the  ordi- 
nary passing  of  sounds. 

The  obtui'ator  of  the  irrigating  instrument  is  withdrawn  in  proof  of 
entrance  into  the  })ladd(T.  'J'he  shaft  is  now  brought  to  the  midline 
of  the  body  and  at  about  90°  to  the  table,  where  it  is  held  by  the  assistant 
in  one  hand,  and  in  the  other  hand  the  penis  and  scrotum  stretched 
and  flattened  along  it  with  a  testis  on  each  side  and  with  the  curve  of 
the  instrument  gently  forced  downward  and  backward  to  make  the 
perineum  prominent  as  the  patient  lies  in  the  exaggerated  lithotomy 
posture  which  is  correct  for  this  operation.  The  superficial  field  is  the 
perineum  from  the  base  of  the  scrotum  to  the  anal  verge  and  the  incision 
is  regularly  in  the  raphe  1|  inches  long,  between  these  two  points  and 
in  depth  includes  the  skin,  superficial  fascia,  and  fat  down  to  the 
bulbous  and  membranous  urethra.  A  stitch  in  each  lip  of  the  wound 
is  the  best  retractor  to  reveal  the  deep  field.  With  the  finger  in  the 
bwer  angle,  the  groove  of  the  staff  is  located  as  it  traverses  from  before 
backward.  The  pointed  knife,  with  its  back  against  the  finger  tip  and 
edge  pointed  forward,  is  now  stabbed  through  the  urethra  and  into  the 
groove  of  the  guide  and  then  lengthens  the  urethral  w^ound  to  the 
approximate  limits  of  the  skin  incision,"  or  at  least  to  three-quarters 
of  an  inch.  The  blunt  point  straight  blade  bistoury  is  now  passed  into 
the  groove  along  the  blade  of  the  scalpel  as  a  director  and  employed 
to  divide  the  stricture  along  the  floor  of  the  canal,  while  the  staff  is, 
if  necessary,  at  the  same  moment  brought  downw^ard  by  the  operator 
in  order  to  carry,  its  groove  well  into  the  bladder  and  thus  guide  the 
knife  to  best  advantage.  This  management  of  the  staff  is  exactly  that 
of  a  sound  in  the  last  step  of  entering  the  bladder  ''penetration." 
The  floor  of  the  stricture  is  thus  divided  throughout  its  length  and  the 
lips  of  the  wound  in  the  urethra  should  be  included  in  the  stitches 
retracting  the  skin.  The  bladder  is  now  entered' upon  the  staff  or 
tunneled  and  grooved  irrigating  sound  w^ith  either  the  director,  the 
catheter  staff  or  the  female  catheter.  The  director  is  to  be  preferred 
(especially  if  the  irrigating  sound  has  been  used)  and  its  blade  should 
be  bent  at  right  angles  to  the  handle  and  slightly  .curved  on  itself. 
After  its  introduction  the  staff  or  sound  is  removed  and  the  director 
remains  as  a  permanent  guide  into  the  bladder  and  evacuator  of  its 
contents  for  the  rest  of  the  operation.  With  the  entire  wound  held 
open,  the  roof  of  the  urethra  is  palpated  and  divided  for  infiltration 
there,  exactly  as  the  floor  was,  and  thus  the  strictured  area  as  a  whole 
is  relieved.  Dilatation  of  the  urethra  with  soimds  from  30  up  to  34  Fr. 
passed  from  the  meatus  to  the  wound,  or  into  the  bladder  or  from  the 
wound  into  the  bladder  and  out  of  the  meatus,  should  now  be  done  in 
order  to  establish  continuity  of  the  canal  and  its  freedom  from  false 
passage  or  pocket.  "Paralj^zmg  of  the  sphincter  of  the  bladder"  by 
passing  the  finger  along  the  director  into  the  viscus  until  the  middle 
finger  is  freely  accepted  without  spasm  of  the  muscle  upon  it  shoidd 
always  be  done  and  results  in  the  same  benefit  to  the  bladder  as 


39S  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

stirtc'hinjj  the  sphincter  of  the  anus  (h)es  to  the  i-ectuin  hy  r(>lie\-in.f!: 
tendenev  to  ])ostoi>erative  si)asni. 

The  complications  of  the  stricture  sliould  be  a})propriately  treated 
as  encountered:  abscesses  are  to  be  o})ened,  drained  and  packed, 
Hstuhv  should  be  divided,  sterilized,  drained,  ]iaeked  or  excised,  and 
false  ])assaij:es  recjuire  free  oiHMiin.u'  into  the  caxity  of  the  iu"(>thra  for 
healing  from  the  i)ottom. 

The  hemostasis  is  important  with  elanij),  ligature  or  stitch,  with 
special  respect  for  the  transverse  perineal  and  bulbar  arteries  and  the 
venous  plexuses,  or  with  firm  packing  around  the  ])erineal  tube  after 
its  insertion  into  the  bladder.  Oozing  after  the  edema  of  com])lieated 
cases  has  ceased  is  often  troublesome  and  ])revented  by  suitable 
packing  and  pressure.  Oozing  may  also  be  checked  by  the  application 
of  tincture  of  iodin,  hot  silver  nitrate  solution,  1  in  2o0,  or  formal- 
dehyde gelatin.  Oomi)()un(l  alum  powder  (Squibb)  solution  is  very 
valuable  indeed  for  this  purpose. 

Irrigation  of  the  urethra  with  hot  styptics  from  the  meatus  into  the 
wound  and  from  the  wound  into  the  bladder  backward  or  forward 
out  of  the  meatus  should  always  be  done,  especially  in  cases  compli- 
cated with  sinus,  fistuhe  and  false  passage.  Irrigation  of  the  bladder, 
especially  in  cystitis,  must  always  be  accom])lished  best  with  the  peri- 
neal tube  to  be  used  for  the  drainage.  The  best  model  of  these  tubes 
is  thick  walled  rubber  against  collapse  and  eyed  at  the  very  tip  of  its 
cone  point,  of  high  quality  and  smooth  surface.  The  purpose  of  the 
terminal  veh'et-eye  is  to  prevent  the  foreign  body  action  of  much 
length  within  the  bladder,  and  consequent  pain  and  tenesmus.  The 
tube  is  inserted  with  the  irrigating  fluid  running,  which  flushes  the 
deep  field  and  posterior  urethra  until  the  eye  is  within  the  bladder, 
then  from  two  to  eight  ounces  are  run  in  according  to  the  known 
capacity  of  the  given  viscus,  evacuated  and  repeated  until  the  outflow 
is  perfectly  or  reasonably  clear.  With  the  bladder  full  the  tube  is 
withdrawn  until  the  outflow  just  stops  under  cover  of  the  s])hineter, 
and  then  advanced  until  free  flow  is  fully  established,  showing  that  the 
eye  of  the  catheter  is  within  the  bladder.  It  should  be  studiously 
directed  upward  to  secure  best  drainage.  At  this  point  it  is  fastened 
with  Lembert  stitches  to  the  skin  and  underlying  fascia  with  the  silk- 
worm retraction  stitches,  which  should  be  disengaged  from  the  urethral 
wall.  ^Yhere  either  much  bleeding  or  cystitis  exists  a  metal  irrigating 
tube  may  be  passed  into  the  bladder.  The  perineal  tube  of  Alexander,' 
the  return  flow  model  of  Ilagner,  or  the  ordinary  female  silver  catheter 
is  available  for  this  purpose  with  provision  for  outflow  beside  the 
instrument  usually  secured  by  the  presence  of  the  director.  Hot 
fluid  is  used  uncil  the  flow  is  clear,  normal  salt  solution  for  cleansing 
and  compound  alum  powder  for  hemostasis  in  almost  any  ordinary 
strength,  as  this  combination  does  not  attack  the  tissue. 

Suture  of  the  wound  is  usually  unnecessary,  unless  at  the  upper  and 
lower  angles  of  long  incisions  in  the  more  difficult  cases. 

'  Medical  Record,  189G,  1,  841. 


OPERATIVE  TREATMENT  OF  STRICTURE  399 

The  director  is  now  removed  and  tlic  <,fuuzc  packing  carefully  applied 
down  to  the  uretliral  wall  held  open  above  anrl  helow  the  stitches 
between  the  tube  and  the  skin.  The  "tent  packing,"  if  necessary,  is 
reinforced  with  a  pyramid  of  gauze  carefully  applied  and  pressed  home 
with  the  approved  model  of  two-tail  T-binder  to  prevent  oozing. 

External  Urethrotomy  with  the  Whalebone  Guide. — Examples  of 
stricture  occur  wliicli  acce])t  the  filifi>rni  guide;  alone,  but  cannot  be 
passed  with  any  of  the  steel  tunneled  and  grooved  irrigating  sounds  or 
staffs.  In  these  the  operation  may  be  done  by  opening  the  urethra 
in  the  healthy  portion,  at  the  distal  surface  of  the  infiltration  and  then 
by  free  retraction  exposing  the  filiform  as  it  enters  the  lumen,  which  is 
slowly  opened  along  it  over  the  floor  and  then  over  the  roof  in  the  same 
method  just  described.  The  stricture  may  be  located  by  passing  a 
sound  to  its  face  or  better,  by  using  the  Wheelhouse  method,  which 
is  described  under  external  urethrotomy,  without  a  guide.  The  danger 
of  following  the  filiform  alone  is  only  that  of  dividing  it,  which  is 
obviated  by  deliberation  and  precision  and  the  use  of  the  silver  probe 
or  small  director  to  open  up  the  canal  every  quarter  inch  or  so. 

Immediate  Aftertreatment. — The  nurse  should  receive  special  orders 
to  observe  hemorrhage  into  the  dressing  and  drainage  into  the  urine 
bottle  every  quarter-hour  for  the  first  three  or  four  hours,  and  the 
latter  thereafter  as  part  of  the  regular  attention  to  the  patient  every 
two  or  three  hours.  The  causes  of  bleeding  are  arteries  or  veins 
uncontrolled  at  the  operation  or  opening  by  cessation  of  edema  in 
virtue  of  the  relieving  incision,  and  the  outer  dressing  by  pressure  may 
cause  backset  of  blood  into  the  bladder,  closure  of  the  catheter  by  clots, 
great  distention  by  the  accumulation  of  urine  and  blood,  secondary 
congestion  and  finally  bleedmg  from  strain  at  evacuation  and  spasm 
at  failure.  In  prevention  all  vessels  should  be  tied  or  controlled  with 
packing,  the  sphincter  stretched  against  spasm,  and  the  bladder  free 
of  pus  and  clots,  and  in  management  the  patient  had  best  be  placed 
on  an  operating  table,  the  drains  renewed  under  increased  pressure, 
after  the  tube  has  been  removed,  cleansed  and  replaced  in  a  bladder 
freed  from  blood  and  clots  in  the  following  steps:  The  perineal  tube 
is  disconnected  at  the  glass  link  into  the  drainage  tube  from  the  col- 
lecting-bottle, and  the  hand  syringe  filled  with  hot  normal  salt  solution 
is  connected  to  it  and  partly  emptied  by  hard,  sharp,  short  jerks  of  the 
piston,  disconnected  and  the  bladder  emptied.  This  process  disengages 
clots  from  the  eye  of  the  tube  and  often  breaks  up  the  larger  clots  for 
evacuation  and  should  be  repeated  until  the  bladder  is  cleaned,  when 
it  is  returned  and  stitched  into  place  and  the  dressing  then  renewed 
under  pressure. 

The  causes  of  failure  of  dramage  of  urine  into  the  bottle  beneath  the 
bed  are  that  the  tube  is  too  far  in  and  its  eye  above  the  level  of  fluid 
until  the  quantity  is  sufficiently  large  to  cause  discomfort,  and  until 
its  own  presence  irritates  as  a  foreign  body,  or  that  it  is  out  so  far 
that  its  eye  is  closed  by  the  sphincter  of  the  bladder,  blood  clots, 
mucous  or  pus  of  cystitis.    The  tube  if  thm  walled  may  be  collapsed 


400  TREAT  ME  XT  OF  STRICTURE  OF  THE  URETHRA 

by  spasm  at  the  neck  of  tlie  bladtlor,  or  tlie  bottle  segment  may  be 
folded  or  twisted  by  the  patient's  limbs  or  bed-clothing.  The  glass 
connecting  link  or  any  ])art  of  the  tnlu^  may  be  clogged  Avitli  urinary 
sediment  and  pus.  In  pre\ention  thick-Avalled  tubes  carefully  pro- 
tected from  ])ressiire  and  cleansed  at  least  every  day  are  to  be  employed 
and  watched-  at  regular  intervals. 

With  oozing  absent  and  drainage  of  urine  established,  instruction 
of  the  ])atient  requires  his  comprehension  that  the  tube  behaves  like 
a  foreign  body,  slightly  irritating  the  bladder  and  exciting  the  desire 
to  m-inate,  both  duly  decreased  by  quiet  in  bed  and  control  of  vesical 
acti^•ity  which  otherwise  first  increases  distress  and  hemorrhage  and 
then  decreases  drainage  of  urine.  Feeling  of  distention  of  the  bladder 
is  to  be  reported  by  the  j)atient,  verified  by  i)ercussion  above  the 
s>Tnphysis  by  the  surgeon,  and  relieved  by  adjustment  and  irrigation 
of  the  tube  just  described.  Sedatives  in  the  form  of  a  small  dose  of 
mor])hin  by  the  needle,  or  an  opium  suppository  in  the  rectum  with 
its  stretched  si)hincter,  are  often  required  during  the  first  hour  or  two. 

The  renewal  of  the  original  dressing  is  not  necessary  for  se^'eral  daj^s 
unless  it  becomes  contaminated  with  decomposed  urine,  when  it  should 
be  taken  down  as  far  as  the  gauze  drains  and  thereafter  built  up  and 
supported  in  the  original  manner.  The  perineal  tube  is  left  in  place 
for  from  three  to  seven  days  with  irrigation  of  the  bladder  at  least 
daily  for  the  longer  residence  and  the  administration  of  suitable  urinary 
antiseptics.  Gauze  packing  for  bleeding  should  remain  unchanged 
until  quite  loose  in  the  wound,  as  disturbance  will  reexcite  hemorrhage, 
otherwise  the  gauze  should  be  refreshed  every  day.  If  an  internal 
urethrotomy  has  been  done  in  the  anterior  urethra  or  if  discharge 
appears  at  the  meatus,  irrigation  of  the  canal  with  a  hand  syringe  from 
meatus  to  wound  should  be  undertaken  and  if  it  is  desirable  to  leave 
the  perineal  tube  in  for  nearly  a  week,  straight  anterior  urethral  sounds 
may  be  passed  at  least  once  down  to  the  tube  on  or  about  the  fifth 
day.  ^Yhen  the  drainage  tube  and  gauze  packing  are  removed,  the 
anterior  urethra  and  the  wound  should  be  washed  with  weak  silver 
nitrate  solution  (1  in  5000  to  1  in  2000),  and  the  bladder  also,  if  there 
has  been  cystitis.  The  open  wound  is  then  treated  on  surgical  principles 
with  gauze  drains  saturated  in  balsam  of  Peru,  or  castor  oil  and  balsam 
of  Peru  in  equal  parts,  or  red  wash  consisting  of  2  per  cent,  zinc  sulphate 
and  tincture  of  lavender  in  water.  The  WTiter's  standard  or  Benique 
irrigating  sound  one  or  two  sizes  smaller  than  the  largest  used  at  the 
operation  should  be  passed  from  meatus  to  bladder  when  the  tube  is 
removed  and  thereafter  at  regular  intervals  slowly  increasing,  such  as 
five,  seven,  ten,  fourteen  and  thirty  days.  A  perineal  pad  of  sterile 
gauze  and  a  good  T-binder  are  employed  while  the  wound  in  the  peri- 
neum is  closing,  thi\)ugh  which  the  patient  will  urinate  in  decreasing 
quantities  until  final  closure,  while  the  urethra  becomes  more  and  more 
the  normal  and  then  the  final  outlet.  The  patient  should  sit  as  a 
woman  does  to  urinate  until  the  wound  is  closed,  to  avoid  accidents 
to  his  clothing,  or  hold  a  pus  basin  between  his  thighs  into  which  both 


OPERATIVE  TREATMENT  OF  STRICTURE  401 

streams  are  received.  If  there  has  been  great  granulation  tissue 
around  the  stricture,  as  shown  by  the  deep  field,  then  instillations  of 
weak  silver  nitrate  solution  with  the  Bangs  syringe  sound,  using  the 
same  size  of  nozzle  as  would  be  employed  for  the  irrigating  sound, 
should  be  adopted  about  once  in  five  days  in  frequency  and  from  1  in 
5000  to  1  in  1000  silver  nitrate  solution  in  strength. 

Remote  Aftertreatment  is  the  same  as  that  necessary^  in  any  other 
treatment  of  stricture  and  has  been  described  under  the  dilatation 
method.  The  most  important  details  are  attention  to  the  chronic 
urethritis  underlying  the  stricture,  remaining  after  the  obstruction 
of  the  latter  has  been  divided,  and  leading  to  a  relapse  rapidly  unless 
it  is  benefited  or  cured,  and  the  passage  of  irrigating  sounds  at  several 
regular  intervals  each  year,  determined  by  the  tendency  of  the  stricture 
to  return,  which  is  various  from  case  to  case.  The  end  result  of  external 
urethrotomy  is  uniformly  good  if  there  are  no  complications  or  false 


Fig.  114. — Pedersen  modification  of  the  Wheelhouse  gmde,  showing  at  the  bottom  the 
groove  in  the  tip  of  the  instrument  for  the  reception  of  the  knife  blade  and  at  the  top 
the  angle  of  the  prominence  of  the  tip  with  the  shaft  and  the  tunnel  and  groove  of  the 
shaft. 

passages,  and  if  the  fibrosis  has  been  fully  di\aded  along  both  the  floor 
and  the  roof  of  the  canal  and  if  suitable  aftercare,  both  immediate  and 
remote,  are  applied.  In  subjects  of  compromised  kidneys,  such  as 
advanced  nephritis  of  pyelonephritis,  the  operation  is  one  of  severity 
and  danger  with  which  the  family  of  the  patient  must  be  fully 
acquainted. 

External  Urethrotomy  without  a  Guide. — Varieties. — The  recognized 
forms  are  the  Wheelhouse  operation,  suprapubic  cystotomy  with 
retrograde  sounding  of  the  m*ethra  and  Sinclair's  method.  Both  the 
methods  of  Wheelhouse  and  Smclaii*  in  certain  cu'cumstances  might 
be  considered  as  external  urethrotomy  with  a  guide,  inasmuch  as  the 
whalebone  filiform  guide  may  in  such  cases  be  employed. 

Selection  of  Case  respects  those  strictures  suitable  for  external  ure- 
throtomy in  which  only  the  filiform  guide  is  accepted  or  no  guide  at  all. 

External  Urethrotomy  of  Wheelhouse. — Instruments  and  Supplies 
duplicate  those  of  external  urethrotomy  with  a  guide  and  include  the 
26 


402  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

^Vheelhollse  staff,  which  is  a  straight  instrument,  grooved  throughout 
its  shaft,  tunneled  for  a  half-nich  at  its  tip,  Avhich  has  a  distinct  pro- 
jection at  right  angles  to  tlie  shaft  at  the  front  surface  of  the  tip.  The 
diameter  of  the  tip  in  the  standard  instrument  including  this  projection 
is  usually  24  Fr.,  which  is  taken  on  the  ground  that  it  is  sufliciently 
small  to  enter  jiracticalh'  every  urethra  and  large  enough  to  make  the 
projection  \-ery  prominent  within  the  urethra  at  the  face  of  the  stric- 
ture. The  author  has  modified  this  instrument  by  cutting  a  groove 
deeply  into  the  projection  so  that  the  knife  readily  engages  in  it  in  the 
middle  line  of  the  urethra,  instead  of  slipping  to  either  side. 

Technic.^ — The  guide  is  passed  down  to  the  face  of  the  stricture 
directly,  if  no  filiform  has  been  passed,  or  over  it  if  one  is  in  sihi.  The 
grooved  lip  of  the  tip  is  now  turned  backw^ard  against  the  floor  of  the 
urethra  where  it  may  be  distinctly  felt  as  two  rather  sharp  points  with 
the  groove  between  them  and  at  or  near  the  distal  face  of  the  obstruc- 
tion. While  the  guide  is  held  in  the  midline  of  the  body,  with  the 
penis  and  scrotum  stretched  upon  it  exactly  as  in  external  urethrotomy 
with  a  guide,  the  finger  is  placed  on  the  prominence  of  the  tip  in 
the  perineum,  and  the  knife  is  penetrated  into  the  urethra  between 
the  two  points  of  the  tip.  This  small  incision  is  lengthened  for^vard 
about  a  haK  inch  so  that  traction  sutures  may  be  passed  into  both 
lips  through  skin  and  mucosa,  and  then  extended  backward  over  the 
stricture  area  up  to  the  anal  verge  exactly  as  in  the  standard  opera- 
tion. The  "Wheelliouse  guide  is  now  removed  and  with  the  aid  of  a 
probe  or  director  passed  along  the  filiform  guide  or  of  traction  on  the 
latter  itseK  the  canal  is  followed  and  opened  along  the  floor  an  eighth- 
inch  or  so  at  a  time  until  the  entire  obstruction  is  opened.  Then  the 
roof  of  the  stricture  is  divided  from  end  to  end  and  the  rest  of  the 
operation,  including  the  immediate  and  remote  aftertreatments  of  each 
case,  duplicates  that  of  external  urethrotomy  with  a  guide,  described 
in  the  preceding  paragraphs. 

If  the  passage  of  a  filiform  guide  has  not  been  possible,  then  the  pre- 
liminary injection  of  a  dye  such  as  indigo-carmine  may  be  employed  to 
penetrate  the  cavity  of  the  stricture.  With  gentleness  and  deliberation 
this  is  almost  always  possible  and  is  of  great  service  in  opening  the 
canal  accurately  after  the  face  of  the  stricture  has  been  exposed  with 
the  aid  of  the  WheeUiouse  guide.  With  the  stricture  canal  thus  laid 
open  the  other  steps  of  the  technic  are  the  same  as  those  just  described. 

External  Urethrotomy  with  Suprapubic  Cystotomy  and  Retro- 
grade Sounding. — Selection  of  Case. — An  impassable  stricture  with 
failure  to  find  the  canal  in  the  perineal  field  of  an  ordinary  external 
urethrotomy  renders  this  operation  necessary,  but  less  advisable  than 
the  method  of  Sinclair. 

Instruments  and  Supplies  embrace  those  of  external  urethrotomy 
with  a  guide  and  include  two  sharp  retractors  and  two  blunt  retrac- 
tors for  entrance  into  the  bladder  and  the  necessary  needle-holder, 
needles,  catgut,  silk,  etc.,  for  suture  of  the  bladder  and  skin  after  the 
operation. 


OPERATIVE  TREATMENT  OF  STRICTURE  403 

Technic. — After  the  standard  external  nretlirotorny  lias  failer]  and 
as  part  of  the  same  sitting  and  after  the  usual  preliminaries,  thrcmgh 
a  median  abdominal  incision,  two  or  three  inches  long,  the  superficial 
field  of  skin  and  underlying  aponeuroses,  muscles  anfl  fascia3  are  exposed 
down  to  the  deep  field  of  the  bladder  wall  crossed  by  the  peritoneum 
in  the  upper  part  of  the  wound.  The  serosa  is  pushed  back  and  the 
bladder  opened  as  near  its  highest  point  as  possible  between  two  stout 
traction  stitches  through  and  through  its  walls  by  an  incision  just  long 
enough  to  permit  inspection  of  its  contents  and  the  passage  of  the  sound 
in  the  retrograde  direction  to  the  proximal  surface  of  the  stricture. 
A  filiform  guide  or  small  woven  sound  may  sometimes  be  passed 
through  and  through  the  stricture  and  then  the  remainder  of  the 
operation  becomes  an  external  urethrotomy  with  a  guide.  Otherwise  a 
sound  is  passed  down  the  urethra  to  the  face  of  the  stricture  and  held 
in  the  usual  position  as  nearly  as  possible  in  line  with  the  retrograde 
sound  from  the  bladder  and  then  the  urethra  is  opened  step  by  step 
in  the  usual  manner  along  the  floor  and  then  the  roof  between  the  tips 
of  the  two  instruments,  often  with  the  aid  of  injected  indigo-carmine 
to  mark  the  canal.  After  the  fibrosis  has  been  fully  divided  and 
drainage  of  the  bladder  carefully  established  with  the  perineal  upper 
wound  in  the  bladder  is  fully  closed  with  two  or  three  layers  of  Lembert 
or  mattress  sutures,  from  which  a  small  cigarette  drain  passes  through 
the  lower  angle  of  the  abdominal  wound  closed  in  the  standard  method 
and  protected  with  the  usual  sterile  dressing.  The  abdominal  drain  is 
removed  in  twenty-four  hours,  the  abdominal  wound  managed  along 
accepted  lines,  while  the  perineal  field  and  drainage  receive  the  atten- 
tion already  noted.  Thus  after  the  closure  of  the  suprapubic  cystotomy 
the  immediate  and  remote  aftertreatment  become  that  of  external 
urethrotomy  with  drainage  of  the  bladder.  The  objection  to  this 
operation  is  the  opening  of  the  bladder  through  the  abdominal  wall 
with  its  added  suffering  and  danger.  The  method  of  Sinclair  accom- 
plishes the  same  purpose  with  the  danger  practically  removed  and  with 
no  suffering. 

External  Urethrotomy  with  Retrourethral  Cystoscopic  Guide. — 
Selection  of  Case. — This  method  was  devised  by  Sinclaii',i  of  New  York, 
for  impassable  strictures  as  means  of  avoiding  the  difficulties  and 
uncertainties  of  external  urethrotomy  without  a  guide  and  the  dangers 
of  suprapubic  cystotomy  and  retrograde  sounding  of  the  urethra  for 
the  same  class  of  case. 

Instruments  and  Supplies  comprise  the  following:  A  three  inch,  15  Fr, 
trocar  and  cannula;  a  five  inch,  12  Fr.  observation  telescope,  spiral 
end  12  Fr.  Herzfeld  eustachian  catheter  and  whalebone  filiform  guides. 
To  these  may  be  added  the  usual  supplies  for  urethral  cases,  especially 
the  source  and  control  of  light  for  the  telescope. 

Technic. — ^Technic  involved  instruction  of  the  patient  as  preparation 
not  to  pass  urine  for  several  hours  before  the  operation  (which  is 

1  New  York  Med.  Jour.,  April  4,  1914. 


p,Q    J  i5._Cannula  .1  and  trocar  B  introduced  into  the  distended  bladder.     (Sinclair.) 


Fig  ii6.-Cystoscope  E  passed  thrmigh  the  cannula  A  for  bladder  inspection  A  so 
shown  are  the  automatic,  flexible  spiral  curved  guide  B  .dth  the  obturato'.  c  ^r^  «,_m  a^so 
with  the  obturator  removed  and  replaced  by  a  fihform  bougie  D  after  the  guide  has 
entered  the  posterior  urethra.     (Sinclair.) 


OPERATIVE  TREATMENT  OF  STUfCTURE 


405 


commonly  the  uDjivoidablc  sitiKitioii  for  most  of  those;  sufferers)  and  the 
usual  cleansing  of  the  held.  The  anesthesia  is  local  or  g(;iieral  and  the 
posture  moderate  Trendelen})urg.  The  trocar  and  cannula  are  now 
plunged  into  the  bladder  from  a  point  one  inch  above  the  symphysis 
l)u})is  directed  downward  and  backward  to  the  general  region  of  the 


Fig.  117. — Combination  trocar,  cannula  cystoscope,  the  cannula  acting  as  a  sheath 
of  the  catheterizing  telescope,  through  which  a  woven,  flexible  metal  guide  may  be  fed 
successively  into  the  prostatic,  niembranous  and  anterior  urethra.      (Sinclair.) 


vesical  outlet.  If  the  bladder  does  not  percuss  well  above  the  sym- 
physis pubis,  it  should  be  filled  with  tlie  hand  syrmge  by  fitting  the 
nozzle  tightly  into  the  meatus  and  slowly  forcing  the  fluid  into  the 
viscus,  which  may  commonly  be  done  in  cases  permeable  to  urine  but 
impassable  to  the  filiform,  especially  if  the  mucosa  is  decongested  with 


40G  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

the  aid  of  adrenalin  and  cocain.  Tf  the  hhidder  cainiot  he  thus  artifi- 
cially distended,  it  is  necessary  to  wait  until  full  of  urine  before  j)ro- 
ceeding.  After  entrance  into  the  bladder  the  trocar  is  removed,  the 
bladder  cAacuated  and  then  thoroughly  irrij^ated  with  a  catheter 
through  the  cannula,  using  a  12  Fr.  in  order  to  ])ennit  the  return  flow 
around  it.  After  the  latter  is  thoroughly  clean  the  bladder  is  com- 
fortably filled  and  the  obserAatiou  telescope  after  testing  the  light  is 
introduced  or  not  according  to  least  expense. 

General  inspection  of  the  bladder  follows  and  localization  of  the 
internal  urethral  orifice,  which  is  as  closely  a])])n)ached  as  possible  by 
manii^ulation  of  the  end  of  the  cannula  and  cystoscope.  The  latter 
is  now  remo^•ed  and  while  the  cannula  is  held  in  position  accurately, 
the  Herzfeld  eustachian  catheter  is  introduced  with  the  spiral  curved 
end  presenting  anteriorly,  straightened  as  it  passes  through  the  tube, 
but  resuming  its  curve  as  it  ai)proaches  the  vesical  outlet.  The  handle 
of  the  eustachian  catheter  is  de})ressed  downward  and  backward  in  the 
midline  of  the  body  toward  the  spinal  column  which  carries  its  flexible 
tip  along  the  urethra  to  the  proximal  surface  of  the  stricture  exactly 
as  depression  of  the  handle -of  a  urethral  sound  carried  its  tip  from  the 
anterior  into  the  posterior  urethra  and  finally  into  the  l)ladder.  Ixectal 
examination  confirms  the  i)osition  of  the  instrument.  The  patient 
is  now  placed  in  a  lithotoni}'  position  and  the  eustachian  catheter  as  a 
retrograde  guide  exposed  in  the  canal  in  the  usual  manner.  A  whale- 
bone filiform  guide  may  be  threaded  through  the  cannula  and  thence 
through  the  strictiu'e  in  the  reverse  direction  in  cases  which  have 
refused  the  guide  from  meatus  to  bladder,  possibly  because  most 
strictures  with  this  behavior  are  acutel}'  obstructed  at  the  anterior 
rather  than  the  posterior  surface.  The  eustachian  catheter  is  now 
removed  through  the  cannula,  and  the  latter  is  then  withdrawn,  a 
stream  of  saline  or  boric  solution  being  forced  through  during  its 
removal.  The  suprapubic  puncture  does  no  harm  and  heals  kindly, 
aided  by  the  usual  perineal  drainage  tube,  which  relieves  all  strain  in 
the  bladder  wound  and  leakage  into  the  perivesical  planes.  This  skin 
wound  is  simply  covered  by  a  piece  of  sterilized  gauze. 

The  foregoing  clever  technic  may  be  carried  out  with  standard 
instruments  of  the  required  sizes,  but  for  the  sake  of  greater  accuracy 
and  convenience  Sinclair  has  made  a  modification  of  this  combination 
of  instruments.  It  consists  of  an  oval  shaped,  No.  IS  French  trocar 
and  cannula,  the  cannula  being  five  and  one-half  inches  long,  and  acting 
as  the  sheath  for  the  cystoscopic  telescope.  The  technic  for  its  intro- 
duction into  the  bladder  is  the  same  as  for  the  smaller  and  original 
instrument  mentioned  abo\^e;  a  No.  5  Fr.  flexible  metal  guide  may  be 
passed  through  this  instrument  and,  under  direct  vision,  fed  into  the 
posterior,  and  even  through  the  anterior  urethra,  thus  acting  as  an 
efficient  guide  for  external  urethrotomy,  when  it  is  impossible  to  pass  a 
guide  from  the  urethra  into  the  bladder.  As  is  so  frequently  the  case, 
standard  instruments  are  for  the  average  operator  who  has  acquired 
skill  in  bladder  and  urethral  work  more  serviceable  than  special  modi- 


ACCIDENTS  OF  TREATMENT  OF  STRICTURE  407 

fi cations  and  the  use  of  the  former  has  the  advantage  of  decreased  cost 
and  maintenance. 

Aftertreatment. — Immediate  and  remote  aftertreatments  are  the  same 
as  those  already  detailed  for  other  forms  of  urethrotomy.  The  little 
wound  in  the  skin  and  the  bladder  made  by  the  trochar  usually  heals 
by  primary  intention  or  with  little  delay. 

Resection  of  the  Urethra. 

Selection  of  Case. — A  tortuous  stricture  without  undue  length  may 
be  resected  and  the  ends  of  the  canal  brought  together.  The  pre- 
liminaries and  supplies  are  the  same  as  for  external  urethrotomy. 

Technic. — The  urethra  is  exposed  well  beyond  the  stricture  through 
the  skin  and  underlying  tissue  as  the  superficial  field,  and  then  the 
stricture  is  removed  from  end  to  end,  including  the  roof,  as  the  deep 
field.  If  the  length  of  canal  lost  is  not  great,  the  ends  of  the  divided 
urethra  are  united  with  great  care  with  fine  needle  and  catgut,  first 
along  the  roof  and  then  the  sides,  but  the  floor  of  the  canal  is  left 
open  for  drainage  and  healing  by  secondary  intention.  The  skin 
incision  is  also  not  closed  but  left  open  for  the  freest  possible  drainage 
down  to  and  around  the  suture  line,  so  that  if  infection  occurs  it  will 
remain  superficial  and  not  penetrating.  In  order  to  immobiHze  and 
rest  the  urethra  a  perineal  drainage  tube  is  employed  through  an  open- 
ing in  the  canal  proximal  to  the  suture  line  and  sufficiently  removed 
from  it  not  to  interfere  in  any  way  with  the  healing.  If  a  large  part 
of  the  canal  has  been  removed  it  may  be  necessary  to  free  the  distal 
stump  from  its  bed  between  the  corpora  cavernosa  in  order  to  obtain 
the  necessary  relaxation  of  the  part  and  freedom  from  tension. 

Aftertreatment. — The  immediate  and  remote  measures  are  as  in 
external  urethrotomy  with  special  emphasis  on  the  passing  of  sounds 
after  the  suture  line  has  closed  in  order  to  stimulate  the  establishment 
of  a  proper  lumen  of  the  canal. 

ACCIDENTS  OF  TREATMENT  OF  STRICTURE. 

Varieties. — ^The  accidents  of  treatment  of  stricture  are  of  two  classes. 
These  are  (a)  hemorrhage  and  false  passage,  which  are  those  produced 
directly  by  the  instrumentation  without  close  connection  with  the 
infectious  element  and  (6)  urethral  infection,  cystitis,  prostatitis,  epi- 
didymitis and  urethritis,  which  are  those  caused  by  the  infectious 
element  with  definite  relation  to  the  instrumentation. 

Urethral  Hemorrhage. — Significance. — ^During  urethral  examination 
and  instrumentation  hemorrhage  of  ordinary  degree  may  occur  and 
be  without  importance  except  as  indicating  either  midue  size  or  force 
of  the  penetration  or  exuberant  granulations.  ]More  copious  hemor- 
rhage is  apt  to  mean  false  passage  with  the  sounds  or  the  division  of 
large  bloodvessels  during  an  internal  or  external  operation. 

Etiology. — Hemorrhage  may  occur  durmg  dilatation  or  operation 
as  just  stated.    It  appears  during  dilatation  largely  in  accordance  with 


40S  TliEATMEXT  OF  STRICTURE  OF  THE  URETHRA 

tlie  force  and  size  of  instrument  used  and  the  -weakness  of  the  nuicous 
nienihrane  encountered  with  its  unhealthy  irritable  granulations 
around  the  stricture,  especially  in  alcoholics,  sy])hilitics  and  sexual 
dehauchers  who  may  indeed  bleed  without  instrumentation.  Metallic 
instruments  are  a  more  potent  factor  than  flexible  and  should  be  when 
])Ossible  supi)lanted  by  the  latter.  After  a  cuttinj?  o])eration  for 
internal  or  external  invthrotomy  the  bleeding  shoAvs  division  of  an 
artery  of  size,  a  venus  plexus  or  an  irritable  granulating  area.  Movable 
parts  of  cystoscopes  and  urethroscopes  may  catch  folds  of  the  mucosa 
and  tear  them,  with  hemorrhage  as  result. 

Pathology.  —  Pathology  in  the  strict  sense  cannot  be  described  for 
this  accident. 

Symptoms, — ]Moderate  bleeding  is  shown  by  a  few  drops  or  drams 
of  blood  which  appear  at  the  meatus  or  in  the  wound,  commonl.y  as  a 
primary  manifestation  inunediately  after  the  withdrawal  of  the  instru- 
ment, but  less  often  as  a  secondary  sign  after  the  patient  has  returned 
home,  gone  to  bed  and  awakened  by  an  erection  with  the  bleeding. 
The  more  active  bleeding  is  also  either  primary  or  secondary  and 
appears  either  after  passing  the  sound  or  the  open  operation  and  may 
reach  e\en  alarming  pro]:)ortions,  so  that  the  bed  will  be  flooded  not 
unlike  a  postpartinn  hemorrhage.  ^Yith  such  a  condition  the  tempera- 
ture rises  and  the  pulse  becomes  rapid,  small  and  thready,  respiration 
excited  and  the  patient  obviously  prostrated  and  alarmed.  If  a  false 
passage  has  been  made  urinary  function  may  be  interfered  with  and 
infiltration  of  the  cellular  planes  of  the  perineum  may  be  perceptible. 

Diagnosis. — There  is  usually  a  history  of  the  cause  of  the  hemorrhage, 
such  as  dilatation  or  operation  on  the  stricture,  which  often  previously 
was  of  the  active  t}'pe  with  discharge,  showing  irritable  granulations 
behind  it.  There  may  be  the  story  of  erection  during  the  night  follow- 
ing such  treatment  proAoking  the  hemorrhage.  The  subjecti\-e  s^Tnp- 
toms  are  an  immediate  hemorrhage,  moderate  or  severe,  after  interfer- 
ence, or  remote  bleeding  after  the  erection,  and  the  objective  signs  are 
the  blood  m  small  or  large  quantities,  staining  or  flooding  the  under- 
clothing or  bed  linen,  and  from  a  tint  of  redness  in  the  urine  to  nearly 
pure  blood  passed  chiefly  in  the  first  glass  or  sometimes  in  all  the  glasses. 
Clots  may  be  expressed  usually  from  the  anterior  urethra  and  less 
commonly  from  the  posterior  urethra.  The  author's  seven-glass  test 
will  serve  to  indicate  the  point  of  the  bleeding  in  some  cases.  The 
Anterior  Urethral  Glass  will  have  much  blood  and  the  Control  Glass 
little  or  none  in  moderate  cases  and  more  in  severe  cases,  although  less 
than  the  first  glass.  The  Posterior  Urethral  Glass  will  in  mild  cases  be 
absolutely  or  practically  clear  but  may  be  filled  with  blood  in  the 
severe  hemorrhages.  The  Bladder  Cdass  is  free  of  blood  imless  the 
stricture  in  having  been  tight  has  momentarily  closed  with  clots,  and 
reflux  into  the  bladder  has  taken  place.  The  Prostatic  and  the  two 
Seminal  Vesical  Glasses  are  negative  for  blood  unless  the  posterior 
urethra  has  been  the  seat  of  stricture  and  operations.  The  urethro- 
scope may  with  caution  serve  to  locate  the  bleeding  points.     The 


ACCIDENTS  OF  TREATMENT  OF  HTIUCTUHK  409 

laboratory  examination  reveals  the  blood  in  moderate  or  larg(i  quanti- 
ties in  addition  to  the  previous  signs  of  the  stricture,  such  as  pus, 
exfoliated  epithelium,  mucus  and  organisms.  The  trcjitmeiit  usually 
results  in  easy  relief  in  strictly  urethral  hemorr])ag<!,  in  the  sense  that 
the  operation  has  not  divulsed  or  incised  into  the  corpora  cavernosa. 
This  distinguishes  it  from  the  essential  hemorrhage  so  often  seen  from 
the  kidney,  bladder,  prostate  and  vesicles  and  not  infrequently  very 
difficult  to  control. 

Treatment. — Minute  bleeding  during  treatment  of  stricture  is  almost 
inevitable,  but  prevention  of  higher  degree  of  hemorrhage  rests  on  gen- 
tleness, soft  instruments,  slow  progress  from  smaller  to  larger  diam- 
eters and  rest  of  the  urethra  for  from  five  to  ten  days  between  treat- 
ments in  the  average  case.  The  curative  measures  in  mild  cases  after 
dilatation  are  hot  urethral  irrigation  with  2  to  4  per  cent,  boric  acid 
water  or  1  in  10,000  potassium  permanganate  solution  and  the  like, 
which  are  both  antiseptic  and  astringent.  Rest  on  the  operating 
table,  office  couch  or  bed  at  home  with  the  penis  held  firmly  in  the 
palm  of  the  hand  exactly  as  the  small  boy  holds  a  cut  finger,  for  many 
minutes,  and  as  often  as  the  bleeding  may  resume  is  efficient.  Ice  or 
heat  locally  to  the  perineum,  abstinence  from  urination  for  several 
hours  and  gentleness  in  the  evacuation  of  the  bladder  are  all  of  value. 
Severe  hemorrhage  after  internal  urethrotomy  or  dilatation  often 
requires  firm,  even  pressure  with  a  pad  of  gauze  placed  along  the  whole 
urethra,  which  is  carried  up  and  laid  along  the  abdomen.  Occasionally 
an  indwelling  catheter  may  be  used  for  twenty-four  to  forty-eight 
hours  as  a  means  of  counterpressure  and  of  rest  of  the  urethra  by 
drainage  of  the  bladder.  After  external  urethrotomy  mild  cases  will 
usually  cease  after  hot  water  is  applied  to  the  wound  by  douche  and 
sponges  or  by  simple  packing.  The  marked  cases,  however,  require 
a  pyramid  of  gauze  assembled  in  the  so-called  tent  dressing  about  the 
drainage  tube  and  forced  into  the  wound  in  all  directions  and  held 
in  place  with  a  well-applied  T-bandage  or  diaper,  which  should  mclude 
a  large  dressing,  covering  the  entire  genitals.  Of  course,  the  depth  of 
the  wound  should  first  be  searched  for  bleeding  points,  which  may  be 
stitched  or  seized  in  artery  clamps  and  tied.  Styptics  by  local  applica- 
tion or  irrigation  are  available  in  all  cases. 

False  Passage. — Definition. — ^A  false  passage  is  an  opening  from 
the  urethra  into  the  surrounding  planes  of  cellular  tissue,  so  that  urine 
may  escape  into  them,  or  a  passage  opening  from  the  urethra  at  one 
point  passing  along  it  and  either  again  openmg  into  the  urethra  or 
into  the  bladder,  so  that  urine  may  more  or  less  pass  through  it.  A 
false  passage  may,  therefore,  either  be  a  blind  pocket  admitting  the 
tip  of  an  instrument  and  urine  or  a  complete  and  more  or  less  patent 
canal. 

Varieties. — The  passage  may  be  superficial  and  short  or  deep  and 
long,  thus  involving  only  the  mucosa  or  the  surrounding  corpus 
spongiosum  and  cellular  planes,  and  thus  concerning  either  the  urethra 
alone  at  one  or  two  points  or  even  the  bladder  and  prostate  in  its 


410  TREAT  ME  XT  OF  STRICTURE  OF  THE  URETHRA 

courso  from  tlu'  urrtlira  to  tlie  bladdiM-.  The  ])assa,uo  may  be  recent 
ami  ^vitlu)ut  ct)m])lications  or  old  and  with  complications,  especially 
extravasation  of  urine  and  abscess. 

Etiology, — Changes  in  the  mucosa  about  a  fibrous  strictiu'c  permitting 
easy  laceration,  ami  the  ])ockets  about  a  dia])lica,uinatie  stricture 
essential  to  its  transverse  ])osition  and  form  are  the  ])redisi)osing  causes. 
Lack  of  skill  and  force  in  the  passing  of  any  instrument  is  regularly 
the  exciting  cause.  All  rigid  instruments,  whether  bougies-a4)oule, 
sounds,  or  catheters,  or  soft  instruments  with  metal  stilets,  and  all 
pointed  instruments  whether  Hexible  or  rigid,  are  specially  likely  to 
cause  false  passage.  The  flexible  should,  therefore,  be  preferred  to 
the  rigid  and  the  olive-point  to  the  cone-point  variety. 

Pathology, — A  stricture  usually  of  tight  and  complicated  variety  is 
])resent,  whose  pathological  features  need  no  comment  be,yond  that 
gixen  on  page  336.  The  essence  of  the  process  is  a  pocket  or  a 
passage  instrumentally  produced  as  a  laceration  passing  from  the  face 
of  the  stricture  along  the  mucosa,  or  into  the  corpus  spongiosum  for 
a  \ariable  distance  and  there  ending,  or  again  emerging  into  the 
urethra  at  any  point  behind  the  stricture  or  even  into  the  bladder 
itself.  The  tissues  involved  are,  therefore,  according  to  its  extent,  the 
urethral  mucosa,  the  corpus  spongiosum,  the  cellular  planes  of  the 
penis,  scrotum,  jjerineum  and  rectovesical  spaces,  prostate  and  bladder, 
all  according  to  circumstances.  The  temporary  lesions  are  those  of  the 
simple  wound  in  the  slight  cases  while  the  permanent  lesions  partake 
of  the  features  of  at  first  sinus  and  later  scar  of  extensi\'e  limits.  The 
complicating  lesions  are  those  of  extravasated  urine  in  the  older  severe 
cases  and  of  cystitis  when  the  bladder  has  been  entered  and  infected 
from  the  general  inflammatory  process.  All  these  features  have  been 
described  as  to  pathology,  each  in  its  own  place  on  pages  33()  to  343. 
The  location  of  the  passage  is  commonly  in  or  about  the  posterior 
urethra,  where  the  majority  of  severe  strictures  exist,  but  occasionally 
it  ma\'  be  in  the  anterior  urethra. 

Symptoms. — The  symptoms  may  be  local  and  systemic,  subjective 
and  objective.  The  subjective  local  symptoms  are  tearing  sensation, 
pain,  hemorrhage  and  sometimes  inability  to  urinate  from  reflex 
inhibition  or  temporary  obstioiction;  and  the  systemic  signs  are 
syncope,  alarm  and  often  the  onset  of  urinary  infection  or  so-called 
fever.  If  extravasation  of  urine  and  abscess  occur  all  the  symptoms 
thereof  previously  described  prevail.  The  objective  local  symptoms 
arise  from  the  behavior  of  the  instrument  after  the  application  of 
force.  The  mucosa  suddenly  yields  and  the  tip  changes  its  normal 
direction  from  the  axis  of  the  urethra  commonly  to  one  or  the  other 
side,  while  the  handle  is  deflected  to  the  opposite  side  and  rotated 
slightly  with  the  beak.  If  the  bladder  has  not  been  penetrated,  rotation 
of  the  instrument  is  not  possible  except  at  the  cost  of  more  violence, 
tearing  and  pain.  With  the  tip  in  the  bladder  rotation  is  possible,  but 
with  an  abnormal  direction  of  the  shaft  and  handle  of  the  instrument 
which  is  pathognomonic.    Hemorrhage  ensues  around  the  shaft  of  the 


ACCIDENTS  OF  TREATMENT  OF  STRICTURE  411 

instrument  and  is  usually  c()})i(jus.  Palj)ation  at  first  along  th(;  distal 
portion  of  the  urethra  u])  to  the  general  region  of  the  strieture  and  then 
proximal  to  it,  will  show  the  shaft  of  the  instrument  in  the  normal 
passage  up  to  the  stricture  and  thereafter  outside  it  and  traceable 
between  the  crura  penis  into  the  perineum,  beneath  the  pubic  arch 
into  the  prostate  or  the  rectovesical  spaces  and  even  bladder  in  excep- 
tional cases.  Rectal  examination  is  therefore  essential  in  these  cases. 
If  extravasation  and  abscess  have  developed,  all  their  objective  features 
as  previously  noted  will  be  added  to  those  of  the  stricture.  Urethro- 
scopy, especially  with  irrigation,  will  reveal  the  wound  in  recent  cases 
and  the  sinus  or  pocket  in  old  cases  and  should  not  be  omitted. 

The  termination  of  mild  blind  cases  is  commonly  prompt  recovery 
without  complications,  but  deep  blind  passages  or  complete  canals 
with  both  openings  in  the  urethra  or  one  in  the  bladder  are  apt  to 
induce  complications  and  never  get  well  without  operation.  The  signifi- 
cance of  false  passage  is,  therefore,  great  if  located  in  the  posterior 
urethra  with  such  involvement  and  complication  of  the  bladder  and 
perirectal,  perivesical  and  periurethral  structures. 

Diagnosis. — The  patient  describes  a  long  or  severe,  continuous  or 
relapsing  history  of  symptoms  of  stricture,  followed  by  rough  or  hasty 
efforts  to  pass  steel  instrmnents,  especially  those  with  small  shafts 
and  more  or  less  sharp  points.  The  subjective  symptoms  are  those  of 
pain  during  the  instrumentation,  followed  by  a  sense  of  laceration 
and  bleeding.  With  these  are  urinary  disturbance  or  even  obstruction 
with  fear,  fainting  and  fever.  The  objective  symptoms  on  palpation 
may  be  the  nodulation  of  the  stricture  surrounded  by  the  edema  of  the 
false  passage  and  the  bogginess  of  the  extravasated  urine  and  the 
subcutaneous  infiltration  of  blood  and  pus.  On  instrumentation  the 
sound  will  deviate  from  the  normal  axis  of  the  urethra  and  cannot  be 
rotated.  A  catheter  does  not  evacuate  the  bladder.  Bleeding  follows 
any  such  instrumentation  as  a  rule.  On  rectal  examination  the  mstru- 
ment  may  be  traced  in  its  course  along  the  urethra  and  into  any  of  its 
cellular  or  glandular  annexa.  Urine,  blood  and  pus  may  be  expressed 
by  the  examining  finger.  The  urethroscope  is  very  serviceable  m  locat- 
ing the  distal  opening  of  the  false  passage,  and  also  the  proximal 
opening  of  those  false  passages  which  leave  the  urethra  in  front  of  the 
stricture  and  enter  it  behind  the  stricture.  The  laboratory  examination 
adds  but  little  more  than  perhaps  blood  and  shreds  of  tissue  in  the 
urine  in  recent  cases.  In  older  cases  the  shreds  and  pus  are  more 
abundant.  In  the  treatment  by  open  operation  the  positive  diagnosis 
is  in  some  cases  alone  reached. 

Treatment. — Gentleness,  patience,  soft  instruments,  full  diagnosis 
of  all  the  characters  of  the  strictm-e  are  the  preventive  measm-es,  and 
there  is  today  less  excuse  than  ever  before  for  this  accident.  Rest  m 
bed  for  a  few  days  at  least  and  total  absence  from  urethral  invasion 
of  any  character  for  several  weeks  are  the  first  curative  measures  in 
mild  cases,  while  m  severe  cases  the  patient  should  remain  in  bed  for 
the  said  two  or  three  weeks  under  light  diet  and  urinary  antiseptics. 


412  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

I  rotliral  irrigation  should  also  not  l>t'  ilono.  The  suruioal  euro  of  the 
stricture  is  the  first  step  in  any  marked  case,  as  restoration  of  the  normal 
caliber  of  the  uretlira  usually  puts  the  false  passage  at  rest  anil  i)romotes 
healing.  Perineal  section  is  the  operation  of  choice  because  it  drains 
the  bladder  and  ])Osterior  urethra  and  absolutely  quiets  the  canal  in 
front  of  the  drain-hole,  and  often  i)ermits  free  ojiening  into  the  wound 
of  the  false  passage  from  end  to  end  Avhose  course  has  been  mdi- 
cated  by  methylene  blue  or  other  dye  and  thus  causes  it  to  heal  com- 
])letely  from  the  bottom.  The  oi)eration  should  ahvays  be  done  with 
a  guide  which  may  connnonly  be  ])assed  with  all  the  aids  detailed  under 
the  dilatation  treatment  of  tight  stricture.  After  hot  styptic  irrigation 
of  the  urethra  a  filiform,  alone  or  after  filling  the  urethra  with  them  or 
through  the  urethroscopic  tube  displaying  the  face  of  the  stricture  or 
alongside  an  instrument  ])assed  into  and  filling  the  false  passage,  may 
commonly  be  made  to  pass  through  the  lumen  of  the  stricture.  If  this 
fails  the  method  of  Sinclair,^  consisting  of  suprapubic  puncture  of  the 
bladder  with  a  trocar  and  cannula,  location  of  the  vesical  outlet  with  a 
cystoscopic  telescope  and  lamj)  and  the  retrograde  passage  of  an  instru- 
ment or  filiform  down  to  the  proximal  face  or  through  the  lumen  of  the 
stricture  and  then  proceeding  with  the  usual  steps  of  perineal  section. 
Or  the  older  operation  of  suprapubic  cystotomy  with  a  guide  inserted 
from  within  the  bladder  ma>'  be  done.  Or  without  a  guide  and  only 
with  the  aid  of  injected  (h'e  stuffs,  perineal  section  may  be  undertaken. 
The  aftertrcatment  of  such  cases  must  respect  both  the  false  passage 
and  the  stricture,  so  that  if  possible  the  former  may  be  made  to  heal 
before  the  urethra  is  allowed  to  close. 

Complications. — The  complications  of  false  passage  already  set  down 
as  urinary  infection,  extravasation  of  urine,  abscess,  sepsis,  sinus  and 
fistula,  have  the  appropriate  treatment  already  described  for  each 
respectively  m  pages  409  to  412. 

Urinary  Infection. — Synonyms. — I'rinary  sejjsis,  urinary  poisoning, 
urinary  fever,  lu'ethral  fe\"er,  urine  fever,  urethral  chill,  urine  chill, 
catheter  fever — a  list  which  confesses  indefinite  knowledge  in  the  past, 
as  to  the  exact  condition  when  fever  was  regarded  as  a  disease  instead 
of  the  sign  of  reaction  by  the  body  to  infection.  The  term  urinary 
infection  is  probably  the  most  definite. 

Definition. — A  nervous  or  septic  state,  or  both  combined,  acutely 
following  lu-ethral  intervention  or  at  times  chronically  associated  with 
long-standing  urogenital  disease. 

Varieties. — Nervous,  embracing  chiefly  shock  and  traumatic,  includ- 
ing chiefly  septic  absorption  or  comlnned,  in  which  traumatism  and 
infection  are  added  to  nervous  debility. 

Etiology. — In  each  form  the  predisposing  factor  is  either  a  naturally 
deficient  nervous  system,  which  reacts  profoundly  to  any  surgical 
incident  or  an  acquired  nervous  weakness  from  se])tic  foci,  and  in  the 
traumatic  or  infective  form  profound  flisease  in  the  kidneys,  bladder, 

'  Loc.  cit. 


ACCIDENTS  OF  TREATMENT  OF  STRICTURE  413 

prostate  and  urethra,  causing  urinary  decomposition,  infection  and  a 
tendency  to  chronic  absorptif)n,  or  to  an  active  acute  ahsorjjtion  througPi 
even  a  minute  wound.  The  exciting  elements  are,  therefore,  the  various 
pyogenic  microorganisms,  especially  the  Bacillus  coli  commnuis,  the 
streptococcus  and  the  staphylococcus  entering  through  an  abrasion 
or  laceration  in  the  urethra  directly  or  indirectly  through  reflex  inhibi- 
tion of  diseased  kidneys  after  instrumentation  of  the  urethra.  Probably 
the  unhealthy  granulating  urethra  proximal  to  a  stricture  is  a  very 
common  portal  of  invasion  of  microorganisms  already  resident  therein 
or  of  such  as  are  in  the  urine  as  it  passes  over  it.  The  decomposing 
urine  of  chronic  cystitis  especially  in  the  retention  of  enlarged  prostate 
and  of  chronic  pyelonephritis  is  undoubtedly  the  most  fertile  source 
of  the  organisms. 

Pathology. — There  is  no  true  pathogenesis  in  nervous  urinary  infec- 
tion as  the  phenomena  are  reflex,  even  when  the  nervous  debility  is 
secondary  to  chronic  septic  absorption.  There  is  a  focus  of  absorp- 
tion in  acute  traumatic  septic  urinary  infection  usually  passive  about  a 
stricture,  in  the  kidneys,  bladder,  or  urine  itself  which  requires  only  a 
very  little  disturbance  to  render  it  active  by  direct  entrance  into  the 
bloodstream.  The  urine  in  chronic  septic  urinary  infection  is  pro- 
foundly altered  chiefly  by  the  Bacillus  coli,  the  streptococcus  and  the 
staphylococcus,  the  kidneys  extensively  invaded  and  the  bladder  the 
seat  of  severe  cystitis  with  the  prostate  hj'pertrophied  below  and  in 
front  of  it.  From  any  or  all  these  niduses,  singly  or  associatedly,  little 
or  no  exciting  factor  will  induce  an  acute  sepsis  grafted  on  the  chronic 
form  already  existing.  The  pathology  of  each  of  these  underlying 
conditions  has  already  been  described  under  its  own  subject. 

Symptoms. — Symptoms  vary  with  the  two  varieties,  neuropathic 
and  septic.  In  the  nervous  type  the  patient  is  timid,  anemic  and  of 
low  resistance.  A  simple  examination,  a  meatotomy  or  the  passing 
of  a  sound  even  without  the  presence  of  a  stricture  but  more  especially 
the  slight  pain  of  dilating  a  stricture  is  followed  by  partial  or  total 
fainting,  a  chill  rarely  with,  usually  without,  temperature  and  malaise 
for  a  few  hours  at  the  most.  Very  rarely  is  there  any  inhibition  or 
stimulation  of  the  kidney  function  and  it  is  doubtful  whether  this  mani- 
festation should  logically  be  classed  under  the  heading  of  urinary  infec- 
tion, excepting  from  respect  for  tradition  in  this  condition.  In  a  patient 
whose  nervous  constitution  has  been  undermined  by  persistent  septic 
absorption  all  these  nervous  phenomena  may  be  added  to  and  increase 
the  conditions  really  proceeding  from  the  sepsis  itself. 

In  the  traumatic,  septic  type  the  cases  are  mild,  severe  and  chronic 
and  show  the  following  s^^nptoms:  In  the  mild  cases  the  patient  has 
for  a  day  or  two  a  chill  followed  by  a  fever  of  occasionally  high  range, 
considerable  depression  and  at  times  decrease  in  the  amomit  of  urine, 
while  his  skin  may  compensate  by  sweatmg.  For  part  of  a  day  or  more 
these  patients  are  quite  sick,  usually  m  bed,  and  then  fully  recover. 
In  the  severe  cases  so-called  acute  urinary  infection — the  chill  is  intense, 
often  prolonged  and  repeated  and  precedes  or  follows  the  onset  of  the 


414  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

fever,  which  may  reach  106°  F.  or  even  more,  with  partial  or  total  sup- 
pression of  urine  for  a  few  or  many  hours.  IVemic  symptoms  as  mild 
or  acti\"e  tlelirium,  profound  clianges  in  tlic  pulse  and  strenjitli  may 
super\-one  so  tliat  all  those  patients  are  rather  dan<j:erously  sick.  The 
termination  in  tlie  majority  is  rcco\'ery  unless  tlie  kidneys  are  much 
involved,  but  the  patients  are  prostrated  for  a  day  or  two  after  the 
crisis.  In  the  minority  of  such  victims  death  may  follow  from  acute 
or  chronic  uremia  and  se])sis  in  a  few  days  and  occasionally  in  a  few 
hours  from  the  combined  total  supj^ression  of  urine  and  its  toxic 
absorption  and  the  low  resistance  of  a  body  already  damaji;ed. 

The  foregoing  is  often  called  acute  urinary  infection  and  arises  from 
seemingly  trivial  causes  in  patients  ha\ing  a  fa^•orable  urological  basis, 
to  distinguish  it  from  chronic  urinary  infection  which  rests  on  such 
persistent  septic  lesions  as  pyelonephritis,  cystitis,  prostatitis,  especially 
with  residual  urine,  stricture  with  urethritis  and  the  various  complica- 
tions of  all  these  conditions,  which  favor  urinary  decomposition,  infec- 
tion and  absor])tion.  From  such  foci  absorption  is  almost  always 
more  or  less  chronic  and  continuous,  against  which  the  system  scarcely 
holds  its  OAVTi,  so  that  a  very  little  irritation  brings  on  an  acute  condition. 
In  the  chronic  and  slowly  progressing  cases  the  patient  nearly  always 
has  more  or  less  fe^•er,  anemia,  ill  health  and  depression,  while  in  acute 
exacerbations  of  this  chronic  state  almost  any  SAiiiptom  complex  may 
arise,  after  severe,  trivial  or  unknown  injury  or  surgical  intervention. 
The  termination  of  these  low-grade  cases  is  in  chronic  or  acute  uremia 
or  lethal  urinary  infection,  of  which  the  latter  two  may  follow  any  of 
the  signs  just  described. 

The  combined,  or  neuroseptic,  type  is  probably  not  a  distinct  entity 
except  in  so  far  as  in  some  individuals  sepsis  reacts  most  upon  the 
nervous  system  so  that  all  the  neurotic  symptoms  are  exaggerated  and 
induced  by  tri\aal  causes  and  then  followed  by  the  more  important 
symptomatology  as  just  described. 

Diagnosis. — The  three  forms  vary  slightly.  In  the  history  the  nervous 
t^7)e  admits  susceptibility  to  fainting  and  other  phenomena  in  slight 
circumstances,  and  the  traumatic  or  infective  form  embraces  lesions 
of  the  kidneys,  bladder,  prostate  and  urethra  as  foci  of  absorption. 
The  subjective  symptoms  are  the  shock  and  temporary  disturbance  in 
the  nervous  tj^pe  but  the  slow  or  rapid,  motlerate  or  severe  infection 
in  the  traumatic  or  infectious  form,  and  the  objective  signs  show  no 
physical  basis  for  the  condition  in  the  nervous  cases  except  the  obviously 
defective  nervous  system.  The  traumatic  septic  patients  may  show 
almost  any  lesion  of  the  annexa  of  the  urethra,  the  urethra  itself  or  the 
urinary  organs  as  the  point  of  onset  as  well  as  all  the  signs  of  sepsis. 
The  laboratorj^  investigation  verifies  the  foregoing  objective  findings 
by  establishing  ])rofound  nephritis,  for  exam])]e,  and  demonstrates  the 
infecting  organisms  in  some  cases. 

Chemical  hematology,  as  discussed  in  Chapter  XV  on  page  863, 
is  the  latest  progress  recognizing  the  influence  of  lesions  like  severe 
stricture  on   the   body.     No  operation  on  severe  and  complicated 


ACCIDENTH  OF  TREATMENT  OF  STRICTURE  415 

stricture  should  be  uiKlcrtaken  without  a  chemical  hematology  for 
toxic  substances  retained  in  the  blood. 

The  treatment  only  adds  the  final  proof  in  combating  the  infection 
by  medicinal  and  serological  methods  or  by  direct  surgical  attack  on 
the  infecting  focus. 

Treatment. — In  urinary  infection  prevention  is  important  and  closely 
related  with  bacteriology,  urinalysis  and  renal  functional  tests  in  every 
severe  case  of  stricture.  The  bacteriology  has  been  dealt  with  suffi- 
ciently under  the  subject  of  diagnosis  of  stricture  on  page  35.3  anrl  necjrls 
no  addition.  Urinalysis  will  reveal  rather  accurately  the  source  of 
epithelium  and  pus  from  urethra,  bladder  or  kidneys  and  the  nature 
of  albumin  and  the  number  and  kind  of  casts.  It  will,  therefore, 
furnish  a  reasonable  forecast  of  the  kidney  function  w^hich  may  be 
further  elucidated  by  the  phenolsulphonephthalein,  indigo-carmin,  urea 
and  other  tests,  all,  of  course,  in  cases  having  permeable  strictures 
through  which  urination  is  still  possible.  If  the  stricture  is  closed  one 
must  proceed  immediately,  with  the  choice  favoring  drainage  operations 
on  account  of  the  ignorance  of  underlying  conditions.  Urinary  anti- 
sepsis may  be  promoted  by  the  administration  of  any  of  the  following, 
salol  grains  5,  sodium  salicylate  grains  5,  formin  grains  5,  urotropin 
grains  5,  and  sodium  benzoate  grains  5,  in  a  glassful  of  water  every  two 
to  four  hours.  The  benzoate  of  soda  may  be  combined  with  the  formal- 
dehyde preparations  with  special  activity  toward  the  Bacillus  coli 
"communis.  Urethral  antisepsis  may  be  aided  by  irrigation  of  the 
urethra  before  and  after  invasion,  when  it  may  be  secured  through 
any  but  a  tight  stricture.  It  is  here  that  the  tunneled  and  grooved 
irrigating  sounds  of  the  writer  are  available  and  his  suggestion  that 
woven  catheters  with  flexible  bougies  as  obturators  be  employed  where 
soft  instruments  are  necessary.  Through  these  the  bladder  may  be 
filled  with  appropriate  antiseptics,  itself  irrigated  if  advisable  and  in 
turn  flush  the  urethra  from  end  to  end  in  Nature's  own  method  with 
the  contained  fluid.  Gentleness  of  instrumentation  and  infrequency 
of  treatment  so  that  the  defective  urogenital  tract  may  fully  recover 
between  each  treatment  are  of  great  importance  as  preventives.  Thus 
dilatation  should  not  be  repeated  oftener  than  every  five  to  seven  days 
if  the  case  is  at  all  severe.  Sedatives  after  the  visit,  such  as  a  pill  made 
up  of  morphm  sulphate,  grains  |  to  J,  tincture  of  aconite,  minims  1 
to  3,  and  quinin  grains  3  to  5,  will  often  prevent  the  nervous  reaction. 
Bodily  quiet  is  always  of  aid  and  rest  is  necessary  for  the  chronic  cases. 

The  curative  measures  of  urinary  infection  actually  present  are,  for 
the  nervous  cases,  rest  in  bed,  a  sedative  for  the  fear  and  nervousness, 
a  stimulant  for  the  prostration  if  present,  followed  by  a  urinary  anti- 
septic and  possibly  diuretic  and  cathartic  in  the  more  marked  cases. 
Urethral  irrigation  is  a  precaution.  In  the  acute  septic  cases  all  these 
measures  must  be  actively  combmed  and  sometimes  continued  for 
several  days.  Normal  salt  solution  is  a  potent  stimulant  of  the  flagging 
kidneys,  applied  to  the  colon  and  rectum  by  the  drip  method  of  ]\Iurphy,i 

1  Jour.  Amer.  Med.  Assn.,  1909,  lii,  1248. 


416  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

now  so  familiar,  or  by  injection  into  a  vein  or  beneath  the  skin  unless 
the  blood-pressure  is  already  very  hiixh.  Hot  packs  and  other  familiar 
preventi^■es  of  lu-emia  are  important.  In  the  chronic  variety  the 
damage  of  the  u])])er  urinary  organs  is  usually  so  profound  that  jireven- 
tion  becomes  the  turning  point  and  imless  successful  subsequent  treat- 
ment is  often  useless.  Its  principles  are  those  just  laid  down  in  that 
the  condition  to  be  met  is  usually  acute  symptoms  supervening  on 
the  chronic  state.  In  the  combined  neuroseptic  t\"i)C  the  nervous  signs 
are  sim])l\-  the  expression  of  the  chronic  pus  absor])tion  and  may  be 
reached  indirectly,  if  at  all,  by  relieving  the  underlying  depreciation 
and  then  treating  the  ner\ousness  as  it  arises. 

Urethritis,  Epididymitis,  Prostatitis  and  Cystitis. — Occurrence. — In 
the  course  of  treatment  of  stricture  any  of  these  accidents  may  occur 
singly  or  all  may  be  \ariousJy  associated  in  one  clinical  picture  as  a 
common  process. 

Etiology. — The  direct  excitation  of  dormant  infection  already 
])resent,  or  the  direct  transference  of  bacteria  from  one  point  of  the 
urogenital  tract  to  another,  is  the  usual  source  of  these  accidents.  The 
direct  excitation  of  inflanmiation  is  by  sounds  too  large,  too  violently 
used  or  applied  for  unduly  prolonged  period.  These  procedures  would 
tend  to  provoke  catarrhal  inflammation  in  a  normal  canal  and  will 
certainly  do  so  in  a  diseased  mucosa,  and  if  the  organisms  of  suppura- 
tion, notably  the  gonococcus,  are  present,  the  field  is  ripe  for  a  fresh 
outbreak  of  localized  or  extending  acute  disease.  The  direct  trans- 
ference of  microorganisms  occurs  by  the  passage  of  an  instrument 
over  a  dormant  focus,  itself  becoming  infected  by  the  pressure  of  i)us 
from  glands  and  pockets  u])on  its  surface  and  then  as  it  passes  forward 
along  the  canal  dragging  this  material  to  new  points  perhaps  of  mod- 
erate traumatism  where  it  engrafts  itself,  thus  also  excites  a  localized 
or  extending  acute  disease,  or  an  infected  instrument  not  properly 
sterilized  may  do  the  harm. 

Urethritis  is  favored  by  the  character  of  the  normal  mucosa  and  the 
condition  of  the  diseased  points  for  an  exacerbation  of  local  or  extended 
distribution.  It  harbors  the  organisms  in  its  mucous  follicles  and 
possesses  little  resistance  to  the  development  and  penetration  of  the 
gonococcus  and  other  pyogenic  bacteria.  It  will  thus  readily  sufl^er  a 
localized  outbreak  immediately  around  the  stricture  Avhere  it  is  pro- 
foundly altered,  or  an  extension  from  this  point  of  onset  or  a  direct 
infection  from  pus-bearing  instruments  proximal  to  the  stricture,  where, 
as  a  rule,  the  congestion  and  traumatism  of  strain  during  passage  of  the 
urine  have  reduced  its  resistance. 

Epididymitis  arises  in  two  difl'erent  manners.  The  mouths  of  the 
vasa  deferentia  in  the  colliculus  may  be  invaded  directly  by  infection 
of  an  exacerbation  of  urethritis  as  just  described.  Or  through  disease 
of  the  entire  urethra  proximal  to  the  strictin-e,  pre^'iously  fully  detailed, 
their  outlets  are  i>atulous  and  will  readily  receive  infectious  material 
carried  into  the  deep  urethra  by  sounds  or  other  instruments.  It  is 
probable  that  traumatism  of  the  more  or  less  diseased  colliculus  itself 


ACCIDENTS  OF  TREATMENT  OF  STUJCTURE  417 

is  a  potent  element  in  these  cases.  The  clinical  features  of  epididymitis 
have  been  described  under  that  heading  on  ])age  1 40  and  will  not  be 
here  repeated. 

Prostatitis  has  been  dealt  with  in  its  clinical  varieties  as  follicular 
and  parenchymatous  involvement  on  page  116,  and  needs  notice 
only  as  to  its  origin  during  the  treatment  of  stricture.  1'he  back 
pressure  from  the  obstruction  traumatizes  the  posterior  urethra  and 
congestion  and  catarrh  of  the  entire  region  follow,  to  which  very  readily 
the  infection  is  added.  In  all  severe  strictures  rectal  examination 
reveals  a  boggy,  indolent  enlargement  of  the  prostate  constituting 
congestion  of  more  or  less  chronic  type.  The  irritation  and  traumatism 
of  instruments  readily  activate  this  process  into  an  acute  catarrhal  or 
suppurative  invasion,  follicular  or  parenchymatous  in  its  distribution. 

Cystitis  arises  either  as  a  direct  result  of  instrumentation  or  of  infec- 
tious activity.  The  instrumental  causes  are:  (1)  direct  trauma  of  the 
neck  of  the  bladder  by  large  instrmnents  in  simple  dilatation;  (2) 
irritation  or  ulceration  of  the  mucosa  by  pressure  in  prolonged  or 
continuous  dilatation;  (3)  exacerbation  of  previous  chronic  urethro- 
cystitis, trigonitis  or  cystitis,  through  even  incidental  instrumental 
contact.  The  bacterial  or  infectious  causes  are:  (1)  direct  extension 
into  the  bladder  of  a  fresh  urethritis  instrumentally  excited  as  just 
described  in  the  preceding  paragraph  on  urethritis ;  (2)  direct  infection 
with  instrument,  pus-bearing  or  germ-bearmg,  either  through  having 
been  improperly  sterilized  before  use  or  through  having  passed  over 
an  infectious  zone  in  the  urethra;  (3)  organisms  may  reach  the  circula- 
tion of  the  blood  through  portals  opened  from  active  foci  by  instru- 
ments, reach  the  bladder  in  the  ordinary  course  of  their  excretion 
from  the  system  by  the  kidneys  and  set  up  cystitis  in  a  viscus  ren- 
dered atonic  and  nonresistant  by  the  strain,  congestion  and  irritation 
of  the  back-pressure  from  severe  stricture.  It  shoidd  in  general  be 
remembered  that  any  of  the  ordinary  organisms  inhabiting  a  diseased 
m-ethra  may  be  at  the  bottom  of  such  infections — a  fact  which  only 
again  emphasizes  the  importance  of  knowing  the  bacterial  conditions 
of  all  severe  strictiu-es.  Cultiu-e  is,  therefore,  the  step  which  will  reveal 
the  virulence  of  the  germs  found,  and  should  always  be  taken.  All 
the  clinical  manifestations  of  cystitis  are  described  in  Chapter  II, 
on  Complications  of  Acute  Urethritis  on  page  166. 

Diagnosis. — These  foiu*  accidents  of  the  treatment  of  stricture  vary 
in  their  diagnostic  details.  In  the  history  there  must  be  absence  of 
these  lesions  followed  by  then-  more  or  less  prompt  occm'rence  after 
the  treatment  of  the  stricture.  The  strictiu-e  itself  is  commonly  of  the 
more  active  type  with  slight  discharge  or  shreds  constantly  present 
and  irritability  under  even  slight  debauches  and  not  uncommonly  a 
positive  bacteriology  for  the  gonococcus  and  its  allies.  Subjective 
and  objective  s^Tnptoms  are  those  distinctive  of  these  fom'  lesions 
as  fully  detailed  under  each  in  Chapters  I  and  IV,  on  Acute  and 
Chronic  Urethritis  and  Complications  of  Acute  and  Chronic  Ure- 
thritis, respectively,  in  Chapters  II  and  V.  The  seven-glass  test  of 
27 


41S  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

the  author  is  availahle  for  tlie  ]>rostatitis  and  tho  cystitis  in  cases 
invohing  any  doubt  and  in  distinguishing"  thcni  from  siin])le  anterior 
or  posterior  urethritis  and  s{)ermatoc>stitis.  The  urethroscope  and 
the  cystoscope  are  vahuible  in  tlie  hiter  i)eriods  when  the  uretliral 
element  is  in  abeyance.  The  limitation  of  these  instrumental  means 
of  diaiinosis  is  that  their  una^■oidable  irritation  of  an  already  vulner- 
able and  nonresistant  nuicosa  sometimes  stinmlates  another  outbreak. 
They  should  therefore  not  be  undertaken  without  gentle  irrigation  of 
the  urethra  at  least  immediately  after  their  em]:)loyment.  The  labora- 
tory adds  the  organisms  res]ionsible  for  the  infections  and  shows  the 
characteristic  epithclia  and  other  ])roducts  froiu  the  bladder,  ])rostate 
and  testes.  The  treatment  in  its  course  will  clear  up  all  doubtful 
points. 

Treatment. — Treatment  of  these  accidents  is  chiefly  preventive 
management,  consisting  in  the  full  diagnosis  of  the  character  and 
infectiousness  of  the  stricture  and  then  in  ])rotection  of  the  system 
against  local  invasion  by  the  administration  of  lu'inary  antiseptics 
and  protection  of  the  canal  by  irrigation  with  mild  antiseptics  before 
and  after  treatment  in  sus])ected  cases.  The  irrigating  sounds  of  the 
author  are  of  extreme  value  in  this  therapeutic  flehl  in  that  the  irriga- 
tion includes  the  bladder  and  the  entire  urethra  in  Nature's  own  process ' 
and  without  the  added  invasion  of  passing  a  catheter  after  a  sound. 
The  curative  treatment  has  already  been  described  under  the  separate 
heading  of  each  accident — m-ethritis,  epididymitis,  prostatitis  and 
cystitis  in  the  chapters  named  on  ])age  417. 

COMPLICATIONS  AND  SEQUELS  OF  STRICTURE. 

Significance. — Stricture  is  in  itself  a  complication  of  gonococcal 
infection  and  may  superinduce  complications  of  its  own  course  or  aug- 
ment those  already  existing,  from  which  it  arose.  In  the  former  group 
are  to  be  classed  the  urinary  complications  in  the  bladder,  ureters  and 
kidneys,  often  of  the  ascending  and  less  frequently  of  the  hematogenous 
t\j>e,  and  also  to  be  included  are  the  sexual  sequels  es])ecially  in  the 
prostate  and  less  commonly  in  the  testicles.  In  the  latter  group  are 
the  urethral  lesions,  especially  the  folliculitis  and  the  chronic  changes 
in  the  proximal  urethra.  These  facts  lend  double  im})ortance  to  the 
cure  of  the  stricture  and  the  relief  of  such  sequels. 

Varieties.  —  Complications  and  sequels  of  stricture  concern  the 
urethra,  the  sexual  organs  about  it  and  the  urinary  organs  above  it  and 
the  general  system.  Each  of  these  complications  is  fully  discussed  as  it 
arises  independently  of  stricture  and  therefore  details  may  be  omitted 
here.  The  urethral  complications  are  urethritis,  due  to  stasis  and 
decomposition  of  urine  and  the  infection,  muscular  hyi)ertrophy  fol- 
lowed by  atrophy  arising  from  strain  to  overcome  the  obstruction, 
false  passages  and  fistuhe  caused  by  muscular  or  instrumental  rupture, 
extravasation,  cellulitis  or  abscess.  The  sexual  sequels  are  the  same  as 
those  in  any  other  posterior  urethritis  which  is  always  present  in  severe 


COMPLICATIONS  AND  SEQUELS  OF  STRICTURE 


419 


stricture,  seminal  vesicailitis,  funiculitis,  epifliflymitis  and  opididymo- 
orchitis.  This  group  of  complications  is  oft(,"n  of  the  rf;lapsing  type 
during  stricture.  The  urinary  complications  mark  i)rogress  of  the  infec- 
tion through  and  above  the  sphincter  of  the  bladder  and  are  cystitis 
often  followed  by  hypertrophy,  atrophy  and  sacculation  of  its  muscular 
coat  through  strain,  ascending  ureteritis  and  pyelitis  either  by  direct 
extension  after  dilatation  or  by  lymphatic  absorption  and  the  later 
developments  of  pyelonephritis  and  pyonephrosis  which  may  also  be 


Fig.  118. — Dilatation  of  the  ureter  and  of  the  pelvis  of  the  kidney  secondary  to  a  chronic 
retention  of  urine  produced  by  a  close  stricture  of  the  xirethra.     (Legueu.i) 

by  direct  progress  from  the  mucosa  of  the  renal  pelvis  or  by  mdirect 
infection  through  the  hTnphstream  or  bloodstream.  The  systemic 
sequels  are  either  high  grade  or  low  grade,  usually  fatal  sepsis  and 
uremia — acute  or  chronic. 

Etiology. — ^The  existence  of  the  stricture  itself  vrith.  the  surrounding 
effects  on  the  urethra  and  its  glands  and  on  the  other  sexual  and  urinary 
organs  through  their  mucosae  is  the  predisposmg  cause.  Any  factor 
which  tends  to  provoke  extension  of  the  disease  from  the  stricture  and 

1  Traite  Chirurgical  d'Urologie,  1910. 


420  TREATMENT  OF  STRICTURE  OF  THE  URETHRA 

its  annexa  is  the  exciting  cause.  Such  a  factor  may  be  systemic  and 
diathetic  as  already  sho^wn  in  m'ethritis  itself  or  ma}-  be  local  through 
sexual  or  other  debauch  and  instrumental  interference  or  improper 
treatment  of  the  stricture. 

Pathology. — ^^All  cases  are  necessarily  of  the  secondary  type,  being 
dependent  on  the  antecedent  stricture  and  its  pathogenesis.  The  pro- 
cesses are  in  their  essence  and  stages  identical  with  those  already 
described  for  the  same  lesions  primary  in  the  various  organs  stated 
imder  ^•arieties  or  secondary  in  them  as  complications  of  other  lesions 
of  gonococcal  m-ethritis.  These  complications  of  stricture  therefore 
involve  the  same  tissues,  and  have  the  same  temporary,  permanent 
and  associated  lesions.  In  the  same  way  the  bacteriology  in  nowise  is 
different. 

Symptoms. — All  the  clinical  features  remain  the  same  in  these  com- 
plications as  haxe  been  already  described  for  them  elsewhere — under 
its  own  heading.  There  is  no  need  therefore  to  discuss  the  subjective 
and  objective,  local  and  systemic  s^inptoms  of  the  onset,  establish- 
ment or  termination.  They  are  simply  engrafted  on  the  symptoms  of 
the  antecedent  stricture. 

Diagnosis. — All  the  complications  and  sequels  of  stricture  are  very  fully 
detailed  under  each  complication  as  it  arises  independently  of  stricture 
and  will  not  be  fully  reviewed  here,  but  the  classification  of  these  sequels 
into  m'ethral,  sexual,  urinary  and  systemic  must  be  borne  in  mind. 
The  urethral  complications  are  largely  recognized  by  the  urethroscope 
and  the  seven-glass  test  of  the  author  as  to  the  chronic  inflammation, 
hypertrophy  and  atrophy  of  the  urethra  and  as  to  the  internal  openings 
of  false  passages  and  fistulae.  Probes  and  filiform  guides  may  be  passed 
through  these  often  from  within  when  impossible  without  the  canal  for 
demonstration  of  extent  and  course.  External  openings  are  usually 
obvious  to  sight  and  touch.  Dye-stufi's  injected  through  external  open- 
ings may  be  seen  to  appear  in  the  field  of  the  examining  instrument. 
Rectal,  perineal  and  penile  palpation  are  good  guides.  The  sexual 
sequels  are  already  fully  diagnosticated  and  differentiated  under  semi- 
nal vesiculitis,  funiculitis,  epididjTnitis  and  epididymoorchitis  under 
each  subject.  An  otherwise  unexplained  relapsing  form  of  any  of 
these  complications  at  once  suggests  stricture  as  its  basis  although 
the  narrowing  may  not  be  tight.  Prostatic  enlargement  acts  in  the 
same  manner,  especially  with  reference  to  the  testicle  and  vas.  The 
urinary  complications,  which  include  inflammation,  hypertrophy, 
atrophy  and  sacculation  of  the  bladder,  ascending  ureteritis,  pyelitis, 
pyelonephritis  and  pyonephrosis,  are  proved  by  the  history  of  onset 
in  the  course  of  severe  stricture,  by  the  subjective  symptoms  and 
objecti\e  findings  on  urinalysis— physical,  chemical,  microscopic  and 
bacteriological — followed  by  suitable  exploration  of  the  bladder  and 
kidneys  with  the  cystoscope  and  ureteral  catheters  as  soon  as  the 
urethral  obstruction  permits.  Further  diagnosis  and  diflerential  diag- 
nosis are  given  under  each  lesion  as  already  stated.  The  systemic 
sequels  of  uremia  and  sepsis  must  be  deduced  from  the  subjective 


COMPLICATIONS  AND  SEQUELS  OF  STRICTURE  421 

and  objective  analysis  of  the  case  as  it  has  progressed  from  the  urethra 
to  the  urinary  system  and  thence  into  the  body  at  large.  Modern 
examination  of  the  blood  for  bacteria,  urea  and  other  products  of 
disease  is  of  great  service. 

Differential  Diagnosis. — Recognition  of  the  complications  and  sequels 
of  stricture  is  set  forth  under  each  foregoing  complication  as  it  arises 
during  anterior  and  posterior  gonococcal  acute  and  chronic  urethritis, 
both  as  concerns  the  distinction  of  the  lesions  from  others  in  the  same 
group  and  also  their  identity  from  other  conditions  of  the  urogenital 
system  or  other  systems.  The  reader  is,  therefore,  referred  to  para- 
graphs on  these  subjects  in  Chapters  II  and  V. 

Treatment, — Treatment  is  after  this  enumeration  obviously  referred 
to  the  paragraphs  on  curative  measures  for  each  of  the  complica- 
tions. The  prevention  is  all-important  and  is  chiefly  embodied  in 
bacteriologic  diagnosis  of  each  stricture  and  in  the  proper  gentleness 
and  graduation  of  treatment  of  the  stricture  itself  and  in  suitable 
immediate  aftercare  of  the  urethra  to  prevent  extension  or  absorption. 
As  already  stated,  active  bacteriology  in  a  stricture  marks  it  as  one 
of  danger  requiring  special  attention.  Abortion  is  futile,  as  in  these 
complications  arising  in  other  circumstances. 

Retention  of  Urine — Retention  of  urine  is  a  symptom  of  stricture 
which  may  be  of  the  acute  type  arising  suddenly  or  of  the  relapsing 
form  recurring  more  or  less  frequently  in  attacks  themselves  acute, 
although  the  condition  may  be  chronic.  The  features  of  acute  and 
relapsing  retention  have  already  been  fully  described  for  these  condi- 
tions as  they  arise  as  complications  of  acute  and  chronic  urethritis, 
in  Chapters  II  and  V  on  the  Complications  of  Acute  and  Chronic 
Urethritis  on  pages  197  an4  331. 

Extravasation  of  Urine. — Synonyms. — Urinary  infiltration  and  rup- 
ture of  the  urethra  with  infiltration  or  extravasation  of  urine  are  the 
other  terms  commonly  applied  to  this  condition.  Rupture  of  the 
urethra  without  extravasation,  especially  of  traumatic  origin,  may 
occur  although  the  reverse  is  the  rule. 

Varieties. — ^Varieties  distinguish  as  to  site,  extravasation  anterior 
to,  within  and  posterior  to  the  triangular  ligament;  in  other  words, 
respectively  penile,  membranous  and  prostatic  extravasation,  inasmuch 
as  the  rupture  is  in  these  portions  of  the  urethra.  Each  has  its  own 
field  of  extension  of  the  urine  within  the  subcutaneous  tissues. 

Etiology. — Etiology  embraces  predisposing  and  exciting  factors,  which 
are  only  local.  The  predisposing  elements  are  the  pathogenesis  in 
the  urethra  proximal  to  the  stricture  as  described  on  page  340.  The 
exciting  cause  is  rupture  of  the  urethi*a  after  sudden  closm-e  of  a  tight 
stricture  by  edema,  through  the  effort  to  force  urination  in  the  majority 
of  cases,  while  in  the  minority  of  cases  careless  instrumentation  upon 
a  tight  annular  stricture  of  narrow  extent  tears  through  the  m-ethra 
around  it,  making  a  false  passage  and  extravasation.  Pressure  of  the 
complications  of  strictm-e  such  as  abscess  of  Cowper's  glands  may  lead 
to  extravasation. 


422 


TREATMENT  OF  STRICTURE  OF  THE  I'RETHRA 


Pathology.— Tlie  laceration  of  the  urethra  followed  by  the  a])pearance 
and  extension  and  decomposition  of  the  urine  in  the  tissues  is  the 
essence  of  the  process,  dependent  of  all  the  factors  in  the  ])athosenesis 
of  stricture  in  the  proximal  urethra  jireviously  detailed.  To  this 
foimdation  is  added  the  rujiture  !)>'  nuiseular  strain  or  the  laceration 
by  instruments  followed  by  the  leakage  of  urhie  at  each  etl'ort  to 
evacuate  the  bladder.  The  edematous  stricture  added  to  the  ante- 
cedent tight  strictuie  before  the  accident  is  followed  by  more  edema 


J 


^   «K^> 


Fig.  119.— Extravasation  of  urine  of  the  tlissfcting  type,  probably  originating  ante- 
rior to  the  triangular  ligament  and  thus  extending  cliiefly  forward  into  the  perineum  and 
scrotum  and  down  the  inside  of  the  thighs  guided  by  the  fascia  attached  to  the  rami  of 
the  pubis  and  ischium.  The  urine  probably  broke  through  the  barriers  of  fascia  on  the 
left  side  and  traveled  backward  over  the  buttock  as  far  as  the  general  region  of  the  hip- 
joint.     (\Yatson  and  Cunningham.') 

from  the  inflammation  caused  by  the  urine,  which  still  further  tends 
to  prevent  resolution.  If  surgical  intervention  now  occurs,  the  process 
ceases  in  these  temporary  lesions;  but  commonly  the  second  stage  with 
permanent  lesions  supervenes,  consisting  in  the  stage  of  decomposi- 
tion of  urine  in  the  tissues  with  infection,  abscess  and  sinus,  and  fol- 
lowed by  systemic  absorption,  often  serious  and  even  of  fatal  degree. 
The  complicating  lesions  of  this  condition  are  chiefly  the  reflex  results 


1  Watson  and  Cunningham:  Genito-urinary  Diseases,  1908,  vol.  i. 


COMPLICATIONS  AND  HEQUELH  OF  STUJCTflRE  423 

in  the  kidneys  due  to  the  altered  hydraulics  in  the  lower  urinary  tract 
and  to  the  septicemia.  Oj^eration  done  at  this  period  often  leaves 
behind  th(>  scars  and  fibroses  of  the  a})scesses,  which  may  be  very  exten- 
sive and  deforming.  The  extension  of  urine  in  the  subcutaneous  planes 
may  be  moderate  or  extreme  and  the  direction  of  travel  of  the  urine 
depends  on  the  anatomy  of  the  planes  of  fascia  of  the  perineimi  and  the 
site  of  rupture  within  them,  as  stated  below. 

FascicB  of  the  perineum^  are  two:  superficial  and  deep.  'J'he  super- 
ficial fascia  has  the  following  extent  and  attachments.  In  the  rectal 
half  of  the  perineum  the  subcutaneous  fat  passes  into  the  ischio- 
rectal fossa.  The  pyramidal  cavity  is  limited  by  the  levator  ani  muscle 
and  the  obturator  fascia.  In  the  penoscrotal  half  of  the  perineum 
under  the  subcutaneous  fat  is  a  definite  layer  of  fascia  prolonging  the 
dartos  backward  and  constituting  the  superficial  perineal  fascia  or 
fascia  of  Colles.  This  layer  is  attached  bilaterally  to  the  rami  of  the 
pubis  and  ischium  along  the  borders  as  far  as  the  tuberosity  of  the 
ischium,  and  posteriorly  between  the  ischial  tuberosity  and  the  central 
point  of  the  perineum  it  folds  over  and  behind  the  posterior  border 
of  the  transversus  perineal  muscle,  and  unites  with  the  deep  perineal 
fascia  as  detailed  below.  An  imperfectly  developed  mesial  septum 
passes  from  the  upper  or  deep  surface  of  the  superficial  fascia  upward 
toward  the  urethra,  and  forward  into  the  scrotum.  Thus  air  forced 
beneath  the  superficial  perineal  fascia  in  one  side,  will  pass  into  and 
balloon  the  scrotum  on  that  side  and  later  penetrate  to  the  opposite 
side  also,  through  defects  in  the  median  septum.  Additional  force 
will  carry  it  upward  over  the  abdomen  as  far  laterally  as  Poupart's 
ligament,  where  the  superficial  fascia  is  attached.  The  air,  however, 
will  not  pass  backward  toward  the  rectal  half  of  the  perineum  nor 
downward  over  the  thighs.  Urine  extravasated  mto  the  same  plane 
of  fascia  will  follow  the  same  course  through  retention  by  the  attach- 
ments of  the  superficial  fascia  of  the  perineum. 

The  deep  perineal  fascia  (subpubic  fascia,  triangular  ligament  of  the 
urethra)  closes  the  pubic  arch  on  the  upper  aspect  of  the  penile  crura 
and  urethral  bulb.  '  Its  two  layers  are  thin,  firm,  fibrous  and  surround 
several  structures.  The  supeificial  or  interior  layer  passes  to  the  peri- 
neal central  point  in  the  midplane  of  the  body,  and  then  to  the  rami 
of  the  pubis  and  ischium  laterally  and  to  the  superficial  fascia  of  the 
perineum  along  the  tranversus  perinei  muscle,  posteriorly  into  the 
angle  between  the  crura  of  the  penis  and  the  rami  of  the  pubis  bulb 
bone  anteriorly.  The  upper  or  deep  layer  separates  along  the  urethra 
into  right  and  left  lateral,  halves,  close  to  the  apex  of  the  prostate,  con- 
tinues into  its  capsule  and  thence  into  the  rectovesical  expanse  of  the 
pelvic  fascia.  Laterally  they  are  united  with  the  obturator  layer  of 
the  pelvic  fascia.  Thus  this  layer  of  fascia  covers  the  anterior  surface 
of  the  levator  ani  muscle  which  is  interposed  between  it  and  the 
rectovesical  fascia  and  is  connected  with  the  anal  fascia  which  passes 
backward  over  the  surface  of  the  levator  ani  muscle. 

1  Quain's  Anatomy,  1892,  Pt.  II,  vol.  ii. 


424  TREATMEXT  OF  STRICTURE  OF  THE  URETHRA 

Urine  extravasated  into  this  la\cr  of  fascia  will,  if  between  the  two 
layers  of  the  tnanj;iilar  ligament,  be  retained  there  until  it  suppurates 
through  or,  if  posterior  to  the  deep  layer,  fill  the  ischiorectal  space  and 
pass  thence  downward  upon  the  thighs  and  buttocks.  From  the  fore- 
going anatomical  details  it  will  be  seen  that  extravasated  urine  must 
travel  in  the  following  direction  according  t.)  the  relation  between  the 
point  oi  rupture  (,i)enile,  membranous  or  prostatic)  and  the  planes  of 
fascia. 

Penile  rupture  has  the  point  of  exit  anterior  to  the  triangular  liga- 
ment, and  shows  its  extravasation  either  hi  the  scrotum  and  groins  or 
in  the  penis  alone.  (1)  In  the  former  case  the  rupture  is  bulbar  in  site 
and  the  urine  is  confined  within  the  dartos  of  the  scrotum  and  the 
superficial  perineal  fascia,  within  which  it  travels  upward  toward  one 
or  both  groins. 

The  superficial  fascia  of  the  thigh  is  attached  to  Poupart's  ligament 
so  as  to  prevent  the  urine  from  reaching  the  anterior,  inner  and  outer 
surfaces  of  the  thigh,  as  a  rule,  but  it  may  travel  from  the  attach- 
ment of  the  penis  and  scrotum  along  the  groin  and  upward  over  the 
abdomhial  wall  in  rare  cases. 

After  it  passes  the  partial  median  septum  of  this  fascia,  it  may  then 
travel  down  the  penis  from  a  scrotal  invasion  or  become  bilateral  from 
a  unilateral  onset.  (2)  In  the  latter  case  the  rupture  is  in  the  pendulous 
urethra  outside  the  dartos  and  the  superficial  perineal  fascia  and  there- 
fore tends  to  pass  along  the  cellular  planes  about  the  corpus  spongiosum 
urethree. 

Membranous  ruyiure  has  the  site  of  escape  of  urine  between  the 
layeis  of  the  triangular  ligament  and  remains  pocketed  in  this  situation 
unless  secondary  abscess  permits  it  to  escape  through  either  anterior 
or  posterior  layer  or  both  into  the  scrotum  or  perirectal  spaces,  respec- 
tively. 

Prostatic  rupture  has  the  focal  pomt  posterior  to  the  triangular 
ligament  and  commonly  in  the  anterior  part  of  the  prostatic  urethra, 
and  is  confined  by  the  deep  layer  of  the  triangular  ligament  and  exten- 
sions of  fascia  to  the  bones  and  muscles  of  the  ischiorectal  fossae.  Its 
median  septum  may  make  the  accumulation  at  first  unilateral  and 
later  bilateral  or  the  lesion  may  be  initially  bilateral.  The  tendency 
of  this  accmnulation  is  not  only  to  invade  the  ischiorectal  fossiie  but 
also  to  extend  backward  over  the  buttocks  and  downward  along  the 
inner  surface  of  the  thighs. 

Sjonptoms. — Symptoms  add  the  features  of  rupture,  extravasation, 
decom])osition,  infection  and  sepsis  to  those  of  a  tight  stricture  fol- 
lowed by  sti'icture  by  edema  or  sudden  closure  from  other  causes,  and 
include  subjective  and  objective  local  and  systemic  elements.  The 
subjective  local  signs  are  the  pain  of  the  rupture  followed  by  the  greater 
and  progressing  pain  of  the  extravasation,  which  is  repeated  and  aug- 
mented by  everv'  act  of  urination  unless  relief  is  prompt  and  efficient. 
If  delayed  into  the  stage  of  decomposition  and  infection  all  the  local 
suffering  of  extending  cellulitis  and  abscess  appear.    The  subjective 


COMPLICATIONS  AND  SEQUELS  OF  STRICTURE  425 

systemic  signs  usually  are  at  the  moment  of  rupture  in  tlie  nature  of 
urethral  chill,  su})n()rinal,  then  supernormal  temperature,  with  wide 
excursions  and  all  the  signs  of  sepsis  in  the  circulatory,  respiratory, 
nervous  and  urinary  system — rapid,  hard  or  thready  pulse,  excited 
respiration,  nervous  irritability  or  depression,  chills  and  fever,  and 
sometimes  anuria,  or  oliguria  in  that  the  patients  pass  less  urine  into 
the  abscess  than  during  its  development.  This  symptom  is  more 
definite  if  there  is  a  sinus  whose  discharge  of  urine  may  be  noted. 
The  objective  systemic  signs  corroborate  these  details. 

The  objective  local  symptoms  involve  the  gentle  establishment  of 
the  site  of  the  stricture  by  means  of  a  soft  instrument  passed  down  to 
its  anterior  surface  behind  which  may  be  felt  the  stricture  itself  and 
then  the  infiltration  which  is  moderate  and  indefinite  in  the  earliest 
period  but  marked  and  extensive  in  the  later  stages  with  all  the  signs 
of  infection,  cellulitis,  abscess,  sinus  and  fistula,  according  to  the  age 
and  neglect  of  the  case.  The  termination  of  extravasation  is  fixed  by 
the  duration  and  violence  of  the  decomposition  of  urine  in  the  subcu- 
taneous planes  of  fat  and  fascia.  In  the  recent  cases  with  prompt 
operative  relief,  which  is  almost  the  invariable  modern  experience,  the 
damage  may  be  comparatively  little  but  in  older  cases,  through 
error  of  diagnosis  or  remoteness  and  inaccessibility  to  competent 
urological  aid,  the  destruction  may  be  very  extensive  so  that  sinuses 
and  dense,  deforming  cicatrices  mark  the  recovery.  Septic  absorption 
commonly  destroys  these  patients  because  strictures  with  extravasa- 
tion are  often  also  those  with  other  severe  complications,  as  in  the 
bladder,  ureters  and  kidneys,  which  rapidly  break  down  under  the 
sepsis.  Improved  methods  of  diagnosis  of  stricture  and  education  of 
the  public  to  know  that  even  when  not  tight  a  stricture  must  be  treated 
are  rendering  more  and  more  uncommon  these  complicated  and  fatal 
cases  in  particular  and  cases  of  extravasation  in  general. 

Diagnosis. — The  two  classes  of  cases,  recent  and  old,  differ  in  their 
points  of  recognition.  Diagnosis  of  recent  cases  rests  on  pain  and 
tearing  sensation  described  by  the  patient  and  the  sudden  passage  of 
the  sound  with  harsh,  raw  feeling  instead  of  smooth  progress  along  the 
canal,  followed  by  deviation  of  the  axis,  imperfect  or  absent  rotation 
and  hemorrhage.  The  urethroscopic  picture  is  often  final.  If  compli- 
cating leakage  of  urine  occurs  it  will  have  the  usual  symptoms  and 
signs  described  under  extravasation  of  urine.  Diagnosis  of  older  cases 
rests  on  history,  changes  in  urinary  function,  urethral  discharge, 
engagement  of  an  instrument  in  the  false  passage  while  the  m'ethra 
may  be  traced  away  from  it,  dense  infiltration  along  the  passage  and 
the  urethroscopic  picture. 

Treatment.  —  Intervention  at  the  earliest  extravasation  of  either 
blood  or  urine  is  the  sole  abortive  measure. 

Prophylaxis. — Conservative  and  consistent  treatment  of  stricture 
comprises  prevention  of  these  severe  sequels. 

Management,  as  a  separate  topic,  is  fully  discussed  in  Chapter  IX 
on  the  General  Principles  of  Treatment  on  page  483. 


426      TREATMEXr  OF  ."^TRICrURE  OF  THE  URETHRA 

Curoiiir  Treaiiiicnt. — The  measures  are  chiefly  surgical  thituiuli  the 
uature  of  the  lesions,  both  causative  and   resultant. 

Physical  measures,  as  usually  recogjii/.ed.  ai)i)ly  only  to  the  recovery, 
foi  the  al)sori)tion  of  exudate,  infiltration  and  other  residua. 

Medieijud  measures  are  not  a\ailal)le  locally  except  against  the 
urethritis  and  after  surgical  relief  of  the  extravasation.  As  applied  to 
the  drainage  and  dressing  of  sinuses  they  are  surgical  means.  By 
systemic  admuiistration  the  septic  or  semise])tic  state  of  extravasation 
is  benefited,  as  shown  on  j)age  '2'A\  under  Sei)ticeinia.  Serumtliera])y, 
by  the  nu^thods  noted  on  page  512,  belojigs  iji  the  same  category. 

Through  surgical  intervention  the  stricture  is  relieved,  the  bladder 
draijied,  and  the  extravasation  evacuated,  drained  and  healed.  Ex- 
ternal urethrotomy  by  methods  shown  on  page  395  opens  the  stric- 
ture and  drains  the  bladder.  Occasiojially  su])rai)ubic  cystostomy  is 
required.  Tlu>  i)aths  of  extra\asation  are  followed  from  the  perineal 
wound  and  all  pockets  incised  and  drained.  Stitches  are  usually 
omitted  and  drainage  and  dressing  are  on  established  siu'gical  princii)les. 

Aftcrtrcdinioit. — Tlie  imiliediate  measiu'es  attend  to  at  least  the 
following  details:  (1)  To  the  urethritis  and  urethra  as  shown  under 
External  I'rethrotomy  on  page  399;  (2)  to  the  bladder  and  urine  as 
indicated  under  the  same  subject  and  under  Cystitis,  on  page  173; 
(3)  the  sinuses  and  pockets  on  general  surgical  lines;  and  (4)  the 
general  c(mdition  of  the  patient  as  described  under  Sei)ticemia  on  page 
235.  Remote  methods  are  clearly  comprised  under  each  of  the  fore- 
going headings  and  also  under  Stricture  on  page  401. 

Cnre. — Pathological  restoration  is  hardly  ever  reached,  as  shown 
under  the  various  subjects  just  noted.  The  stricture  always  requires 
sounds  for  life  and  the  infiltratiims  of  the  extravasation  never  totally 
absorb.  Complete  symptomatic  cure  is  the  rule  in  well-managed  cases. 
Bacteriologic  cure  is  discussed  under  Stricture  in  general. 

URETHRAL  INFECTIONS  IN  CHILDHOOD  AND  OLD  AGE. 

Gonococcal  Infection  from  Infancy  to  Puberty.  —  Occurrence. — 

Boys  are  less  frequently  infected  than  girls  through  anatomical  pro- 
tection of  the  parts. 

Varieties. — Acute,  subacute  and  chronic,  anterior,  posterior  and 
anteroj)osterior  urethritis  are  seen.  Complications  are  less  common 
than  in  adult  life  through  undevelopment.  Gonococcal  and  non- 
gonococcal types  are  distinguished. 

Etiology. — All  the  factors  are  the  same  as  in  later  years.  Of  special 
importance  are  the  nongonococcal  causes — dentition,  worms,  vesical 
and  renal  disease  and  faulty  diet. 

Pathology. — The  lesions  are  the  same  as  those  in  adult  life  noting 
the  greater  rarity  of  complications. 

Symptoms. — Subjective  symptoms  during  the  prodromata  and  incu- 
bation are  usually  described  by  children.  The  establishment  is  much 
the  same  as  that  seen  in  adults. 


URETHRAL  JNFECTIONH  IN  CJIILDIIOOD  AND  01  J)  AGE     427 

Diagnosis. — A  physical  cxHiniiiution  and  Ia})f)rat()r\'  |>n)of  of  the 
gonococciis  are  re(Hiirecl. 

Differential  Diagnosis. — As  in  the  juhilt,  distinction  irinst  he  reached 
between  the  gonococcal  forms  and  other  varieties,  such  as  catarrhal 
and  croupous  lU'cthritis  and  jneatal  infections. 

Treatment. — Expectant  methods  alone  are  possible  on  the  same 
principles  as  those  applied  in  the  adult. 

Gonococcal  Complications  from  Infancy  to  Puberty. — Occurrence. — 
Through  physiological  and  anatomical  undevelopment,  complications 
are  very  rare. 

Varieties. — Genital  and  extragenital  classifications  are  observed  and 
under  each  exactly  the  same  forms  may  occur  as  are  seen  in  the  adult. 
The  most  important  extragenital  types  are  conjunctivitis  and  arthritis. 

Symptoms  and  Treatment. — The  clinical  characteristi(;s  and  manage- 
ments are  the  same  as  those  employed  for  the  adult. 

Gonococcal  Infection  in  Old  Age. — Occurrence. — With  the  decline 
of  sexual  powers  infection  decreases.  The  unfaithful  infected  young 
wife  of  an  old  man  is  the  commonest  source  of  disease. 

Varieties. — The  forms  are  the  same  as  those  seen  in  vigorous  man- 
hood. 

Etiology. — Coitus  with  a  prostitute  is  fairly  common  among  ignorant 
old  men,  but  much  less  so  among  the  intelligent.  Innocent  infections 
in  wedlock  are  not  unusual. 

Pathology. — The  lesions  are  the  same  as  those  in  middle  life  with 
distinct  tendency  to  prostatic  infection. 

Symptoms. — In  every  respect  the  clinical  features  are  the  same  as 
those  during  sexual  activity. 

Treatment. — All  accepted  and  conservative  measures  are  applicable. 


CHAPTER    VIU. 
GEXEILVL  rUlNCIPLES  OF  DIAGNOSIS. 

Elements  of  Diagnosis.— I'hore  are  four  general  subdivisions  of  the 
subject  of  (liaunosis,  and  as  in  the  frame  of  a  picture  all  nnist  be  present 
for  the  complete  object.  These  elements  are:  (1)  history,  (2)  physical 
examination  Avhich  must  be  (a)  general  and  local  by  the  standard 
methods  of  inspection,  mensuration,  palpation,  percussion,  and  aus- 
cultation and  (h)  local  by  special  means,  such  as  bacteriology,  instru- 
mentation, m-ethroscopy,  cystoscopy  with  occasionally  its  allies, 
ureteral  catheterization  and  .r-ray;  (3)  laboratory  examination,  embrac- 
ing the  bacteriology  of  smear,  culture  and  urine,  hematology  for  the 
complement  fixation  test  and  toxic  accumulation  of  blood  elements 
and  general  urinalysis,  and  serums,  bacterins  and  phylacogens  and  the 
cOmi^lement  fixation  test  are  all  new  elements  in  diagnosis  and  treat- 
ment obtained  from  the  researches  of  modern  bacteriology  and  cannot 
be  disregarded;  (4)  treatment  with  its  results. 

Each  will  be  fully  discussed  in  its  proper  turn,  in  its  relation  with 
diagnosis.  The  special  instruments  and  equipment  which  belong  to 
the  science  of  Urology  are  detailed  in  this  work  as  their  use  for 
investigation.  Such  description  does  not  include  such  instruments  as 
cystoscopes  and  m-ethroscopes  and  their  accessories,  which  are  fully 
noted  in  the  chapters  dealing  with  cystoscopy  and  urethroscopy,  and 
does  not  include  any  notice  of  .r-ray  apparatus,  which  would  require  a 
voliune  of  its  own,  although  the  radiologist  is  the  right-hand  man  of 
the  urologist. 

The  aims  of  examination  are  the  diagnosis  of  at  least  the  following 
featm*es  concerning  urethral  infection  in  general: 

1.  The  determination  of  discharge  by  smear,  culture  and  at  times 
inoculation  of  animals. 

2.  Inspection  of  the  surface  of  the  lining  of  the  urethra  from  end  to 
end,  including  the  neck  of  the  bladder  and  the  meatus. 

3.  Study  of  the  essential  glands  of  the  mucosa  diu"ing  the  second 
step  just  mentioned,  which  must  embrace  the  glands  of  Cowper 
through  their  ducts. 

4.  The  various  sexual  organs  in  direct  relation  with  the  urethra, 
that  is  to  say,  the  prostate,  seminal  vesicles  and  testicles. 

0.  The  blood  test  for  the  gonococcal  complement  fixation  test  in 
clu-onic  cases. 

G.  Urinalysis  for  elements  of  infection  washed  from  the  urethra 
with  the  urine,  and  signs  of  renal  and  ^•esical  disease  which  may  ensue 
upon  the  urethritis  as  complications  or  be  a  basis  of  local  ill  health 
on  which  the  gonococcal  urethritis  has  been  engrafted. 


II I  STORY  429 

The  social  importance  of  correct  diagnosis  requires  recognition  of 
the  natureiof  the  infection  on  account  of  its  cornrnunicabiHty  in  most 
varieties  of  urethritis,  and  determination  of  the  location,  penetration 
and  complications  of  the  disease,  because  this  knowledge  is  the  basis 
of  treatment  in  the  comprehensive  sense  and  of  curability.  The  per- 
sistence of  the  infection  is  the  one  deciding  element  of  cure  and  mar- 
riageability and  of  the  possible  transmission  of  unsuspected  disease  in 
wedlock.  These  principles  apply  to  both  males  and  females  and 
become  of  grave  importance  when  one  recognizes  the  destructive 
character  of  gonococcal  invasion  in  both  sexes  and  remembers  that 
the  sexual  act  involves  in  its  close  personal  contact  the  primary  means 
of  infection  and  that  its  normal  frequency  only  multiplies  this  means. 
These  facts  are  the  reasons  why  venereal  infection  should  be  treated 
as  a  special  field  of  medicine  in  the  hands  of  trained  experts,  when 
such  are  available,  and  the  reasons  why  even  these  specialists  should 
spare  no  scruple  or  conscientiousness  to  reach  a  final  diagnosis  in  every 
case  before  treatment,  during  treatment  and  before  discharge  from 
treatment. 

HISTORY. 

History  Form.— The  following  outline  of  history  has  for  years  been 
of  great  service  in  the  author's  private  practice  and  by  a  system  of 
abbreviations  has  been  reduced  to  the  size  of  a  piece  of  paper  eight 
by  ten  inches,  so  that  with  the  minimum  of  T\Titing  a  full  record  is 
made  in  a  few  moments,  largely  by  crossing  out  titles  with  negative 
findings  in  the  given  case,  and  by  using  symbols  and  signs.  The  points 
embraced  in  this  form  of  record  follow. 

Name;  Residence;  Nativity;  Race;  Age;  Sex;  Civil  Condition; 
Vocation.     Case  Niunber;  Date ,  19     ;  Referred  by  Dr. 

Diagnosis.— Urethritis:  number  of  the  attacks,  acute,  subacute, 
chronic,  anterior,  posterior,  gonococcal,  nongonococcal.  Complica- 
tions; Sequels;  Result. 

Former  General  History.— ^Family  history,  father,  mother,  brothers, 
sisters,  living  and  health,  dead  and  disease;  wife,  female  diseases, 
children  and  miscarriages. 

Personal  History.  —  General  health  with  special  reference  to  resist- 
ance to  infections,  duration  of  ordinary  illnesses,  catarrhal  conditions 
and  other  diathesis,  previous  infectious  disease  with  respect  to  renal 
and  other  complications;  weight;  appetite;  bowels  and  any  other 
indications  of  general  health.    Habits  as  to  alcohol  and  tobacco. 

Former  Venereal  History.  ^ — Syphilis  (pox,  great  pox,  lues,  blood 
disease  and  hard  chancre):  date  of  chancre;  diagnosis  and  treatment 
by  physician,  dispensary,  druggist  or  self  -vNith  mternal,  inunction, 
injection  or  fumigation;  diu-ation  of  treatment.  Physical  examination 
as  to  skin,  mouth,  anus,  hinphatic  glands,  hair  and  bone,  yon- 
syphilitic  Lesions:  chancroid  (soft  chancre,  eating  chancre,  haircut); 
herpes;  warts;  number  of  attacks,  date  of  last  attack;  diagnosis  and 
treatment  by  physician,   dispensary,   druggist   or  self;  duration  of 


430 


GEXEFiAL  PRIXCIPLES  OF  DIAGNOSIS 


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432  GENERAL  PRINCIPLES  OF  DIAGNOSIS 

treatment  with  caustic,  powder,  wet  dressing,  irrigation ;  date  of  cessa- 
tion of  treatment;  complications,  character,  treatment  and  result. 
Physical  examination  as  to  scars  of  lesions,  comi)lications  or  o])crations. 

Urethritis:  nimiber  of  attacks,  severe  attacks,  prolonged  attacks, 
date  of  last  attack;  complications  in  any  attack,  balanitis,  balano- 
posthitis,  phimosis,  parai)himosis,  bleeding,  adenitis,  epidi(hinitis, 
funiculitis,  prostatitis,  urethrocystitis,  cystitis,  abscess,  rheumatism 
in  joints  aft'ected;  sjiccial  subjective  symptoms  not  covered  by  the 
foregoing  heailings.    Diagnosis  and  treatment  by  physician,  disi)ensary, 

druggist  or  self,   for period;  with  internal,    injection,   irrigation 

methods;  ceased  under  orders  or  by  own  volition. 

Present  Venereal  History.— Sexual  habit,  intercom"se  every days 

or  weeks,  with  any  or  special  woman,  date  of  infecting  intercourse. 
Urethritis:  duration  and  incubation  of  present  attack;  time  of  onset  of 
subjective  sxTnptoms  after  intercoiu'se;  time  of  appearance  of  discharge 
after  intercourse;  character:  thin,  thick,  scanty,  moderate,  copious, 
'  mucous,  purulent,  bloody;  scalding,  preputial,  meatal,  lu'ethral,  anterior 

or  posterior;   diurnal   iu*ination  and  nocturnal  urination  every 

hours;  control,  urgency,  tenesmus;  blood  before,  after  or  with  urination; 
chordee;  special,  subjecti\'e  s.Miiptoms  not  co^'ered  by  the  foregoing 
headings.    Diagnosis  and  treatment  by  physician,  dispensary,  druggist 

and  self  for period  with  internal  injection  and  irrigation  method; 

stopped  by  physician  or  own  volition. 

Complications  (following  exactly  the  same  list  and  form  as  just 
stated  in  the  previous  paragraph). 

Physical  Examination. —  General  condition;  bacteriologic  examina- 
tion (smear,  cultm-e  and  complement  fixation);  discharge;  thin,  thick, 
scanty,  moderate,  copious,  mucous,  purulent,  bloody.  Urinary  speci- 
men I,  II,  III,  IV,  V  (five-glass  test  of  Wolbarst);  edema,  balano- 
posthitis,  l}Tnphangeitis,  foreskin,  glans,  meatus,  methra,  testes, 
epididymes,  cords,  prostate,  seminal  vesicles  and  groins. 

The  adoption  of  such  a  logical  and  consecutive  scheme  as  the  fore- 
going insures  a  careful  history  as  the  starting-point  of  a  proper  diag- 
nosis and  does  not  require  much  time  after  experience  as  headings  with 
negative  findings  may  be  crossed  out  and  symbols  employed  to  save 
WTiting. 

PHYSICAL  EXAMINATION. 

General  Considerations. — As  already  stated,  the  physical  analysis  of 
the  case  must  be  general  and  local  by  the  standard  methods  of  inspec- 
tion, mensuration,  palpation,  percussion  and  auscultation,  and  must 
be  also  local  by  special  means,  such  as  bacteriology,  instrumentation, 
urethroscopy,  cystoscopy,  with  occasionally  its  allies,  ureteral  catheteri- 
zation and  .r-ray. 

General  Examination  need  not  be  minute,  as  the  infection  is  chiefly 
local  in  its  manifestations,  but  such  factors  as  temperament,  jaundice, 
anemia,  edema,  cyanosis,  injury,  operation  and  the  like,  may  be 
rapidly  noted  as  having  an  influence  on  the  general  bodily  resistance 


PHYSICAL  EXAMINATION  433 

of  the  case.  Temperature  should  be  taken  and  signs  of  septic  absorp- 
tion noted  in  pulse,  respiration  and  general  appearance,  if  fever  is 
present.  On  the  whole  it  may  be  said  that  given  good  bodily  health  the 
infection  will  be  more  rapidly  and  fully  controlled  than  in  the  over- 
worked, ill-housed,  anemic  neurasthenic  type. 

Local  Examination  has  been  schematically  presented  in  the  previous 
pages  as  part  of  the  history  chart  whose  headings  may  now  be  more 
fully  detailed.  By  inspection  is  noted  the  condition  of  the  foreskin, 
sheath,  dartos,  and  pubic  region  for  edema  and  cellulitis,  and  the 
scrotum  for  enlargement  of  its  contents  and  the  groins  for  adenitis. 
Lymphangeitis  may  rarely  be  seen  in  mixed  infections  with  severe  com- 
plicating balanoposthitis.  A  distended  bladder  may  be  suspected  from 
suprapubic  prominence  and  reduced  respiratory  motion.  Mensuration 
belongs  more  properly  to  the  special  instrumental  investigation.  By 
external  palpation  are  verified  the  findings  of  inspection  as  to  the 
character  and  involvement  of  the  edema  and  cellulitis,  and  on  with- 
drawing the  foreskin  the  condition  of  its  lining  and  the  glans  and  then 
by  opening  the  meatus  its  edema  and  other  conditions,  especially 
associated  chancre,  chancroids  or  other  ulcers,  and  especially  the  dis- 
charge, thin,  thick,  scanty,  moderate  or  copious;  mucous,  purulent  or 
bloody.  Along  the  venter  of  the  penis  the  urethra  may  be  traced 
for  severity  of  the  inflammation,  thickenings,  nodes,  strictures, 
abscesses,  adhesions,  sinuses  and  the  like. 

In  palpation  of  the  urethra,  as  indicated,  an  instrument  may  or  may 
not  be  within  the  cavity  of  the  canal,  with  gain  in  definiteness  of  the 
findings  by  the  latter  step,  which  is,  however,  available  only  in  the  late 
subacute  or  chronic  stages  when  active  symptoms  or  infection  have 
largely  or  fully  disappeared.  Palpation  without  an  instrument  may  be 
employed  at  any  period  of  the  disease  along  both  the  anterior  and 
posterior  portions  of  the  canal  and  should  not  be  omitted  during  the 
first  visits  of  the  case  and  often  reveals  the  conditions  just  noted. 
Palpation  with  an  instrument  may  be  done  with  a  steel  sound,  or,  as 
the  writer  prefers,  with  an  olive-point,  cone-tip,  lead-core  dOator, 
which  is  much  less  apt  to  offend  excitable  foci.  Either  instrument  may 
be  passed  only  as  far  as  the  bulb  or  into  the  bladder,  which  should 
always  be  washed  afterward  as  a  precaution  and  moderately  filled 
with  warm  feeble  antiseptic,  such  as  silver  nitrate  solution  1  in  5000, 
argyrol  3  per  cent.,  or  protargol  0.5  per  cent.  In  the  anterior  urethra 
nodules,  thickening  and  stricture  are  readily  determined  by  this  step. 
Nodules,  large  or  small,  few  or  many,  insensitive  or  tender,  without 
or  with  adhesion  of  the  skin  commonly  mark  points  of  im'olvement 
of  follicles  and  usually  of  persistence  of  infection.  Thickening  of  the 
urethra  as  a  whole,  suggesting  a  deep  urethritis  or  periurethritis,  is  less 
common  than  single  or  multiple  zones  of  thickening,  which  indicate 
the  early  stages  of  infiltration  and  strictiue.  Thi'ough  the  rectum, 
the  condition  of  the  bulb  and  in  the  posterior  m-ethra  disease  of 
Cowper's  glands  just  within  the  anal  verge  and  of  the  prostate  farther 
up  the  bowel  are  more  fully  described  under  rectal  examination  below. 
28 


434  GENERAL  PRINCIPLES  OF  DIAGNOSIS 

The  limitations  of  such  urethral  palpation  are  that  the  anterior  portion 
and  the  bulb  are  best  examined  and  the  posterior  portion  far  less 
because  literally  the  glands  of  (^owper  and  the  prostate  so  closely 
surround  the  canal  that  the  latter  is  inaccessible  to  the  fin<i:er.  Even 
in  the  anterior  m-ethra  that  portion  of  the  corpus  sponji:iosum  which  is 
dorsalh'  attached  to  the  corpora  cavernosa  is  not  reached  at  all.  In 
all  circumstances,  therefore,  the  suggestions  of  urethral  palpation  must 
be  verified  by  anteroposterior  urethroscopy. 

Chorded  lymphatics,  especiall>'  on  each  side  of  the  dorsal  midline, 
may  be  traced  along  the  penis  into  either  or  both  groins,  where  they 
terminate  in  adenitis  of  congesti\e  neocellular  or  suppurative  type — 
all  connnonly  pointing  to  a  complicating  mixed  jn-ogenic  infection 
usually  of  the  foreskin  or  glans.  The  dartos  should  be  felt  for  local  or 
general  infiltrations,  or  edema  and  adhesions  to  the  testes  or  bulb. 
Each  testicle  is  then  examined  with  the  fingers  in  regular  order  as  to 
the  gland  itself,  the  epididymis  in  its  globus  major,  body  and  globus 
minor,  and  the  vas  deferens  throughout  its  extent  from  testicle  to 
internal  abdominal  ring.  The  appearance  of  overdistended  bladder 
may  be  pro^■ed  by  palpation  from  above  downward  in  the  middle  line 
and  laterally  from  each  side.  Tenderness  along  the  groin  must  suggest 
inflammation  in  the  vas  deferens,  l.vmphatic  channels  or  glands,  or  the 
early  stages  of  hernia,  which  must  never  be  out  of  view  in  diagnosis. 

Internal  palpation  or  rectal  examination  should  always  be  part  of 
manual  exploration  of  the  case  and  in  the  average  patient  is  best 
]3erformed  by  the  following  relative  positions  of  the  patient  and  operator: 
The  patient  stoops  over  the  side  of  the  table  resting  upon  his  elbows 
or  over  a  chair  seat  resting  upon  his  hands,  with  his  feet  about  eighteen 
inches  apart  and  rotated  inward.  This  attitude  opens  the  gluteal 
cleft  and  relaxes  the  glutei  for  ready  access  to  the  anus.  Ha^'ing  pro- 
tected himself  with  rubber  gloves  or  the  finger  cot  ^^dth  rubber  shield, 
or  a  rubber  finger  cot  and  gauze  as  shown  in  Fig.  21,  the  siu-geon 
stands  directly  behind  the  patient  and  inserts  his  lubricated  index 
finger  into  the  anus  and  seciu-es  penetration  and  rest  by  pressure  upon 
his  elbow  with  his  hip  of  the  same  side,  which  without  muscular  force 
by  the  forearm  leaves  the  hand  and  forearm  free  for  only  palpation  of 
the  bulb  of  the  urethra,  prostate,  seminal  vesicles,  and  ( 'owper's  glands. 

The  other  postures  for  rectal  examination  are  the  lithotomy,  right 
or  left  lateral  and  knee-chest;  but  they  are  of  less  service  than  the 
foregoing  position  because  massage  of  the  prostate  and  collection  of  a 
specimen  A\hich  are  essential  to  a  complete  examination  cannot  be 
well  carried  out  in  these  attitudes. 

The  indications  for  rectal  examination  are  that  it  is  proper  in  all 
cases  of  urethritis  in  the  male  as  part  of  a  thorough  investigation. 
Acute  forms  of  the  disease  may  readily  be  discovered  in  the  bulb, 
posterior  urethra,  prostate,  Cowper's  glands,  seminal  vesicles  and  even 
with  certain  limitations  in  the  bladder,  and  chronic  forms  of  obscure 
diagnosis  may  be  properly  determined  at  least  as  to  their  chief  focus, 
complication  and  predominating  nature. 


PHYSICAL  EXAMINATION  435 

Each  anatomical  part  is  rccof^nizof]  in  rcKular  order  and  then 
explored  systematically  as  to  size,  outline,  surfac(;  anrl  (changes  in  the 
density,  such  as  hardness,  softness,  spottiness,  si)onginess,  bulging, 
pulsation,  tension  and  fluctuation. 

The  meaning  of  pain  during  rectal  examination  is  usually  explained 
as  follows:  If  its  site  is  lateral,  the  lobes  of  tin;  j>rostate  may  be 
regarded  as  involved,  i)rovided  especially  that  they  also  reveal  other 
conditions  consonant  with  the  pain.  If  its  site  is  central  and  the 
corresponding  region  of  the  prostate  is  negative  for  other  signs,  then 
it  may  be  assumed  that  the  urethra  is  severely  affected.  In  any  event 
full  analysis  of  these  suggestions  must  be  made  with  the  urethroscope 
and  possibly  the  cystoscope. 

Bulb  of  the  Urethra. — The  bulb  of  the  urethra  is  found  in  the 
normal  course  of  this  passage  immediately  in  front  of  the  triangular 
ligament  and  in  relation  with  Cowper's  glands  and  their  ducts,  if  dis- 
eased. These  ducts  empty  into  it  and  may  in  rare  cases  be  traced 
there.  The  bulb  may  be  prominent  or  almost  imperceptible  according 
to  its  condition  of  inflammation  or  health,  and  like  the  anterior  urethra 
as  a  whole  is  best  felt  with  an  instrument  in  the  urethra,  such  as  a 
flexible  bougie  or  a  steel  sound.  As  in  the  other  portions  of  the  anterior 
urethra  such  examination  may  reveal  nodules,  thickening,  stricture 
and  sometimes  the  corded  ducts  of  Cowper's  glands,  all  of  which  must 
be  duly  verified  by  urethroscopy. 

Glands  of  Cowper. — Anatomy. — The  glands  of  Cowper  are  anatomi- 
cafly  between  the  layers  of  the  triangular  ligament  and,  therefore, 
just  above  and  slightly  lateral  to  the  bulb,  which  brings  them  just  in 
front  of  the  apex  of  the  prostate,  where  they  may  be  grasped  between 
the  index  finger  within  the  rectum  and  the  thumb  upon  the  perineum 
and  their  general  condition  elicited.  The  normal  gland  is  not  palpable 
but  the  diseased  organ  may  show  any  variety  of  change  from  infiltra- 
tion to  abscess  and  sinus.  The  examiner  should  be  familiar  with  all 
these  ordinary  changes. 

The  points  of  anatomy  to  bear  in  mind  therefore  are  that  the  glands 
are:  (1)  between  the  layers  of  the  triangular  ligament;  (2)  just  above 
and  lateral  to  the  bulb  of  the  urethra;  (3)  directly  inside  the  anal 
verge  and  (4)  provided  with  rather  long  ducts. 

Pathology. — ^The  facts  of  pathology  to  remember  are:  (1)  that  the 
normal  glands  are  not  palpable;  and  (2)  that  the  diseased  glands  may 
have  either  patent  or  occluded  ducts. 

Technic  of  Examination.^ — The  posture  for  examination  may  be  the 
lithotomy,  the  lateral,  the  knee-chest  or  the  standing-and-stooping 
posture  which  has  just  been  described  under  rectal  examination  on  page 
434,  and  is  much  to  be  preferred  to  all  others  because  exammation 
and  treatment  of  the  prostate  may  be  done  without  changing  the  pos- 
ture of  the  patient  in  any  way.  Luys^  describes  a  position  as  follows : 
"For  the  exploration  of  these  glands  the  patient  should  lie  flat  on  his 

1  Text-book  on  Gonorrhea,  1913,  p.  102. 


436  GENERAL  PIUXCIPLES  OF  DIAGNOSIS 

back,  the  thijrhs  and  leu;s  hc'nvj;  seniiHexeil,  with  the  heels  togetlier  and 
the  knees  sejiarated."  The  steps  of  the  examination  are  external  and 
internah  External  inspection  and  palpation  may  reveal  a  perfectly 
normal  perinenm  or  a  distinct  protrnsion  on  one  or  both  sides  with 
redness  and  infiltration  of  the  skin  over  it.  Internal  palj^ation  through 
the  anus  is  done  with  the  ])alm  toward  the  object  examined  as  in  all 
other  procedures  and  therefore  in  this  toward  the  base  of  the  bkulder. . 
The  finger  and  liand  are  protected  with  a  rubber  glove,  stall  and  gauze 
shield  or  stall  and  rubber  shield  already  described  in  Fig.  21.  After 
having  passed  the  anal  verge  the  ])rostate  is  first  reached,  its  apex 
recognized  and  in  front  of  this  the  bulb  of  the  uretlwa  traced  forward 
as  far  as  possible.  On  either  side  of  the  bulb  practically  opposite  the 
apex  of  the  prostate  are  located  the  glands  of  CoA^-per,  perceptible  only 
in  disease.  With  the  index  finger  at  the  ])ro])er  ])oint  within  the  rectum 
and  with  the  thmnb  oppt)site  it  u])on  the  siu'face  of  the  perineinn,  the 
mass  of  this  body  is  carefully  explored  between  them  either  from  the 
midline  outward  or  from  without  inward  until  certain  that  nothing 
showing  disease  is  present.  Properly  done  the  position  of  the  index 
finger  ^\•ill  corres]iond  Avith  the  lower  border  of  the  posterior  layer  of 
triangular  ligament.  A  diseased  gland  appears  as  a  body  of  about  pea- 
size  or  larger  and  from  hard  to  boggy  in  consistence  according  as  the 
one  or  the  other  pathological  state  exists,  with  occlusion  and  without 
occlusion  of  the  duct.  The  laboratory  diagnosis  rests  on  securing  a 
proper  s})ecimen  which  is  possible  only  in  cowpcritis  without  occlusion 
and  by  the  following  steps:  (1)  flushing  of  the  lu-ethra  free  of  pus,  by 
having  the  patient  evacuate  a  full  bladder  or  by  irrigating  the  bladder 
and  urethra  artificially;  (2)  irrigation  of  the  anterior  urethra  as  a  con- 
trol of  the  former  step;  (o)  expression  of  the  contents  of  the  gland,  by 
the  same  details  of  massage  employed  for  the  prostate  but  carefully 
avoiding  the  prostate  in  any  of  the  manipulations;  (4)  evacuation  of  the 
boric  acid  water  left  in  the  bladder  at  the  end  of  the  first  step  into  (5) 
sterile  bottles  for  the  laboratory. 

In  coA\-peritis  with  occlusion  no  specimen  may  be  obtained  until  the 
duct  opens  either  in  the  process  of  Nature  or  under  the  influence  of 
massage,  hydrotherapy,  electrotherapy,  dilatation,  and  surgical  treat- 
ment, as  described  on  pages  112  to  115.  A  specimen  must  be  secured 
at  the  time  of  operation  for  drainage  or  extirpation  of  the  gland.  As 
in  other  diagnoses  Aerification  through  anterior  and  posterior  urethrO- 
scoi)y  must  be  secured  before  final  deductions  may  be  reached. 

Prostate  Gland. — Anatomy. — The  anatomy  of  the  prostate  should 
be  well  understood.  Its  apex  is  immediately  inside  the  rounded  mass 
of  the  sphincter  ani  muscle  with  only  the  bulb  of  the  urethra  below  it. 
Its  lateral  margins  extend  outward  to  right  and  left  until  in  the  normal 
gland  a  level  is  reached  by  its  base  within  easy  reach  of  the  examining 
finger.  From  the  base  forward  to  the  apex  again  the  lower  surface  of 
the  gland  is  traversed  by  the  finger.  In  the  average  normal  case, 
therefore,  the  prostate  is  api)roximately  the  size  of  a  very  large  horse 
chestnut,  of  regular  outline,  smooth  surface,  with  a  middle  sulcus 


PHYSICAL  EXAMINATION  437 

between  the  lateral  lobes  and  uniform  firmness  as  of  the  flexed  bieeps 
in  a  woman  and  without  sensitiveness.  ']'he  finger  should,  therefore, 
deteet  general  or  cireumseribed  enlargement.  Modulations  and  other 
irregularities  of  surface.  The  gland  may  be  hard  or  soft,  spotty  or 
spongy  or  of  irregular  consistence.  There  may  be  signs  of  hypertrophy, 
general  or  circumscribed,  upon  which  the  infection  has  been  engrafted. 
The  tension  of  the  pus-producing  process  usually  leads  to  bulging  of 
the  gland,  with  definite  elasticity  and  often  with  pulsation.  Fluctua- 
tion is  much  less  common  than  uniform  tension  and  firmness,  probably 
on  account  of  the  thick  capsule  of  the  gland.  In  the  nature  of  the  lesion 
instrumental  examination  is  not  possible  during  the  acute  periods. 
When  the  inflammation  has  subsided  the  urethra  may  be  cautiously 
explored  wdth  a  soft  instrument  and  the  gland  examined  upon  it. 
Pain  and  tenderness  are  prominent  features,  corresponding  with  the 
tension  which  leads  to  pressure  on  the  nerves  and  with  the  activity 
of  the  infection  which  causes  their  irritation  are  prominent  over  the 
gland  as  a  whole  in  generalized  prostatitis  and  over  the  affected  lobe 
in  localized  prostatitis. 

Examination  of  the  Prostate. — The  close  relation  of  the  prostate  with 
the  posterior  urethra  makes  it  a  very  accessible  organ  for  invasion  and 
its  anatomical  constitution  renders  it  highly  susceptible  to  infection 
from  this  canal  and  its  histological  structm'e  renders  cure  of  invasion 
most  difficult.  One  should  ever  remember,  therefore,  this  clinical  fact 
and  along  with  it  the  indications  of  prostatic  exploration  in  every  case 
of  m'ethritis  as  only  one  detail  of  a  full  examination.  Such  indications 
are:  (1)  congestion  present  in  nearly  all  cases  is  mild  in  piu-ely  anterior 
urethritis,  severe  in  posterior  lesions  and  intense  in  complications; 
(2)  suppuration,  occurring  in  the  late  severe  cases,  is  either  focal  as  a 
single  abscess  or  multiple  abscesses,  or  generalized  throughout  the 
gland  as  a  whole.  The  systemic  reaction  in  these  cases  may  be  so  pro- 
found as  to  simulate  severe  infection,  such  as  tj'phoid  fever.  The  author 
recalls  a  patient  who  was  so  ill  at  the  advent  of  prostatic  suppuration 
that  he  went  to  bed,  summoned  his  family  physician,  who  diagnosed 
typhoid  fever  and  treated  him  for  it  for  nearly  three  weeks.  This 
treatment  was  without  result.  During  the  absence  of  the  author 
another  surgeon  was  called  in  and  recognized  the  prostatic  abscess, 
which  should  have  been  perfectly  obvious  and  unmistakable  all  the 
time,  if  the  family  physician  had  been  careful. 

The  postures  have  been  fully  described  in  the  previous  paragraph  on 
rectal  examination  and  need  not  be  repeated  here  except  in  the  detail  of 
positive  preference  for  the  standing-and-stooping  attitude;  but  the 
preliminaries  should  never  be  omitted  and  include  a  call  by  the  patient 
with  full  bladder,  its  evacuation  to  wash  the  m-ethra  as  clean  as  possible, 
irrigation  of  the  anterior  and  posterior  m-ethra  to  complete  the  cleansing 
possibly  left  imperfect  by  the  urine,  and  distention  of  the  bladder 
with  normal  salt  solution  or  2  to  4  per  cent,  boric  acid  water,  with 
which  the  results  of  prostatic  examination  are  washed  into  several 
receptacles  for  examination.  The  seven-glass  test  of  the  author  should 
always  be  done  in  advance  in  order  to  determine  the  lesion  as  posterior. 


43S  GEXEIiAL  PRIXCIPLES  OF  DIAGNOSIS 

Tlie  ]irecautions  are  against  fainting  of  tlio  patient,  due  either  to 
pain  or  fear,  or  both,  and  against  an  ejnjjty  hladik^r,  whieli  destroys 
the  support  of  the  gland  necessary  for  a  competent  diagnosis,  and 
against  viokMice  of  nianipuhition,  which  will  bruise  the  congested  or 
infectecl  gland  and  excite  severe  absori)tion  and  reaction  and  against 
omission  of  lavage  of  the  bladder  and  the  administration  of  urinary 
antiseptics,  especially  if  instruments  of  any  kind  have  been  used. 
Systemic  reaction  may  be  avoided  by  putting  the  patient  to  bed  for 
one  or  more  days  and  giving  him  a  pill  of  morphin  gr.  J  to  :l'(or  codeine 
gr.  5  to  1),  quinine  gr.  5  and  tincture  of  aconite  1U  i-iii  (or  nitroglycerine 
f^if)  according  to  his  sthenic  or  asthenic  tyjie. 

The  methods  are  of  two  classes:  clinical  or  standard  and  special  or 
corroborative. 

(A)  C'linical  or  standard  exi)loration  of  the  prostate  includes: 

1.  Ixcctal  examination. 

2.  ^Massage. 

3.  Laboratory  analysis  of  secretion. 

4.  jNIensuration. 

(B)  Special  or  corroborati\'e  examination  of  the  prostate  embraces: 

1.  Urethroscopy. 

2.  Cystoscopy. 

3.  Roentgenology. 

The  other  classification  of  these  examinations  is  into:  (A)  non- 
instrumental,  which  embraces  the  rectal  exploration  and  laboratory 
test  and  massage;  and  (B)  instrimiental,  which  iuNoh'es  mensiu'ation, 
urethroscopy,  cystoscopy  and  .r-ray. 

The  technic  is  the  same  for  both  the  rectal  examination  and  the 
massage,  just  stated  as  the  first  two  methods,  except  that  in  massage 
the  mani])iilation  is  more  prolonged  with  the  purpose  of  expressing  or 
milking  the  gland  free  of  its  contents — normal  or  abnormal.  With 
the  preliminary  preparation  already  described  in  the  paragraph  on 
internal  palpation  or  rectal  examination  as  to  the  bladder  and  urethra, 
the  attitude  of  the  i)atient  and  the  protection  and  })osition  of  the  sur- 
geon, the  finger  is  inserted  into  the  rectum  and  ad\'anced  to  the  highest 
part  of  the  gland  in  the  middle  line  and  then  passed  laterally  to  the 
angle  of  either  lateral  lobe.  The  anatomical  arrangement  of  the  ducts 
must  be  here  borne  in  mind,  on  the  point  that  they  pass  radially  toward 
the  uretlu-a  on  all  its  aspects  but  chiefly  along  the  floor  in  the  general 
region  of  the  coUiculus.  Therefore;  in  order  to  drain  the  acini  i)roperly, 
the  pressure  must  be  placed  and  directed  in  the  same  general  manner. 
The  author  therefore  prefers  to  make  pressure  lateromesially  beginning 
at  the  angle  of  one  lateral  lobe  and  passing  step  by  step  until  the  apex 
of  the  gland  is  reached  and  then  to  rei)eat  the  same  procedure  on  the 
other  lateral  lobe  and  finally  on  the  middle  lobe  over  the  urethra.  It 
is  certainly  a  mistake  to  perform  massage  in  a  more  or  less  irregular 
manner  from  side  to  side.  The  proper  action  is  a  scooping  motion  over 
the  field  as  just  described. 

The  clinical  factors  developed  during  prostatic  examination  and 


PHYSICAL  EXAMINATION  439 

massage  may  be  summed  up  as  follows:  (1)  congestion  is  shown  by 
softness  and  slight  enlargement,  somewhat  like  the  parallel  condition 
in  the  skin;  (2)  tension  represents  the  next  step  with  elasticity  and 
firmness;  (3)  a  single  abscess  without  evacuating  sinus  possesses  promi- 
nence, elasticity,  hrmness,  heat,  tenderness  and  sometimes  fluctuation, 
either  in  a  definite  portion  of  the  gland  or  its  whole  body;  (4)  a  single 
abscess  with  evacuating  sinus  possesses  a  soft  spot  where  the  promi- 
nence had  previously  been,  easily  depressed  with  an  outflow  of  pus; 
(5)  multiple  abscesses  without  or  with  sinuses  will  be  indicated  by 
prominences  or  depressions  with  the  other  separate  features  already 
stated. 

The  laboratory  analysis  of  the  secretion  is  the  next  method  and  is 
really  part  of  the  preceding  detail.  Only  sterile  receptacles  should  be  ■ 
employed,  which  are  best  a  glass  funnel  and  bottle  (to  avoid  pouring 
from  a  graduate  into  a  bottle  with  risk  of  contamination^,  standing 
either  on  a  stool  between  the  patient's  knees  or  held  beneath  the  penis 
by  the  patient  himself  or  an  attendant.  In  cases  of  much  disease  of 
the  prostate,  a  rather  copious  specimen  will  be  secured  by  allowing 
it  to  drip  from  the  urethra  or  stripping  it  out  into  the  receiver.  This 
is  specimen  No.  1  and  subsequent  specimens  are  secured  by  having 
the  patient  evacuate  the  fluid  previously  passed  into  his  bladder, 
which  may  constitute  several  additional  bottles.  These  should  be  of 
sufiicient  size  to  permit  the  four-glass  test  fof  clinical  judgment  of  the 
case  exactly  as  though  urine  were  under  inspection.  All  the  bottles 
are  then  sent  to  the  laboratory  for  full  physical,  chemical,  microscopic 
and  bacteriological  examination  and  report,  which  will  be  consonant 
with  the  clinical  findings. 

The  microscopic  features  are  shown  in  the  illustrations  on  page 
315,  which  have  been  taken  from  the  work  of  Oberlaender  and  KoU- 
mann,^  and  their  modern  interpretation  is  contained  in  the  abstract  of 
Young's  paper  on  pages  317-318. 

Mensm'ation  is  the  next  procediue  and  is  the  first  strictly  instru- 
mental step,  involving  the  use  of  flexible  or  rigid  instruments,  wdth 
preference  for  the  former.  The  flexible  instruments  may  be  the 
double-headed  bougie-a-boule  of  Pasteau  having  the  centimeter 
graduations  on  its  shaft,  or  a  special  catheter  suited  to  the  case  with  a 
lead  core  dilator  in  it  as  an  obturator,  to  afford  suitable  resistance  of 
the  urethra.  The  olive  head  of  the  bougie-a-boule  causes  much  less 
distress  than  the  cone  head  and  should  always  be  used.  The  rigid 
instruments  may  be  any  sound  or  catheter  accepted  by  the  urethra, 
with  special  emphasis  on  the  advantages  of  the  author's  model  of  irri- 
gating sounds  in  permitting  lavage  of  the  bladder — a  procedure  which 
had  best  be  regarded  as  essential  to  this  work.  The  really  technical 
steps  are  that  the  apex  of  the  prostate  is  carefully  located  with  the 
finger  in  the  rectum  and  then  the  bougie-a-boule,  catheter  or  sound  is 
advanced  into  the  bladder  a  distance  noted  on  the  shaft  of  the  instru- 

1  Die  Chronische  Gonorrhcs,  Leipzig,  1901. 


440  GENERAL  PRIXCIPLES  OF  DIACXOSIS 

meiit  at  the  meatus.  Hero  atiaiii  the  graduated  instriuuent  of  Pasteau 
and  the  eatheter  or  irrigatuig  sound  of  the  author  all  determine  the 
point  of  entrance  into  the  bladder  accurately,  either  by  the  jump  of 
the  ball-head  throu<;h  the  s])hineter  or  the  gush  of  urine.  The  diagnostic 
points  are  siunmed  up  in  the  urethral  length,  direction  and  dexiation 
and  the  prostatic  thickness  with  other  characteristics  of  the  gland — 
all  in  exact  analog>'  with  the  palpation  of  the  urethra  on  indwelling 
instrimients.  The  chief  justification  of  the  use  of  rigid  instrmnents  is 
that  by  rotation  and  withdrawal  and  similar  manipulations  it  is  possible 
to  estimate  the  })rotrusion  of  the  inHamcd  gland  into  the  bladder  with 
deformity'  of  its  floor.  In  gonococcal  conditions  two  facts  must  never 
be  forgotten,  however,  (1)  that  the  passage  of  instrmnents  is  often 
difhcult  or  impossible  and  should  always  be  followed  by  lavage  and 
sterilization  of  the  cavity  of  the  bladder,  and  (2)  that,  if  possible,  the 
urethroscope  ami  the  cystoscope  should  be  given  preference,  because 
they  permit  inspection  of  the  bladder  and  the  urethra  before  the  palpa- 
tion is  attempted — to  the  mutual  corroboration  of  both  steps. 

Urethroscopy,  cystovrethroscopy  and  cystoscopy  are  the  last  methods 
of  examining  the  prostate  and  should  be  considered  together  becasue 
correlated  intimately.  The  science  of  m'etlu'oscopy  is  considered  in 
Chapter  XII  in  final  detail,  but  its  broad  principles  belong  here  and 
include  both  anterior  and  posterior  lu-etlii'oscopy  at  the  same  sitting 
and  preferably  with  a  water-dilating  instrmiient,  because  this  type 
unfolds  the  crevices  of  the  canal  and  permits  inspection  of  recesses 
which  would  otherwise  escape  notice.  Its  limitations,  when  applied 
to  prostatic  disease  in  the  strict  sense,  are  great  because  it  reaches 
only  the  siu-face  of  the  urethra  while  the  diseased  prostate  is  beneath 
this  siu-face.  It  follows,  therefore,  that  one  may  judge  of  prostatic 
disease  only  in  accordance  with  the  condition  of  the  lu-ethral  mucosa 
in  the  direct  light  of  the  uretliroscope  and  in  the  reflected  light  of  the 
various  other  clinical  findings.  Such  features  of  the  urethral  mucosa 
are  in  the  epithelimn,  the  anatomical  details  and  the  ducts  and  embrace 
color,  vessels,  edema,  elasticity,  crj'pts  and  ducts,  granulation  tissue 
and  ulcers.  The  colliculus  or  vermnontanmn  is  the  chief  anatomical 
feature  containing  the  utriculus  masculinus  and  the  ducts  of  the  seminal 
vesicles  slightly  in  front  and  on  either  side  of  it.  Likewise  important 
are  the  prostatic  fossettes  on  either  side  of  the  colliculus  and  slightly 
behind  it  containing  along  their  floor  the  largest  number  of  prostatic 
ducts. 

As  a  matter  of  routine  and  good  faith  with  the  patient  the  posterior 
urethroscopy  should  be  followed  by  the  same  inve^,  tigation  of  the 
anterior  canal  and  preceded  by  investigation  of  the  neck  of  the  bladder. 
In  the  prostate  the  response  to  a  uretliritis  varies  from  a  simple  sym- 
pathetic congestion  to  infection  and  suppuration,  so  that  in  the  acute 
congestive  conditions  the  mucosa  will  be  inflamed  but  hardly  edematous, 
but  in  the  severe  mfective  lesions  the  whole  process  is  much  more 
marked  and  obvious.  In  the  chronic  conditions  the  ducts  of  the  pros- 
tate will  be  found  patent  and  discharging  thick  strings  of  mucus, 


PHYSICAL  EXAMINATION  441 

mucopus  or  pus  easily  detachable  or  adherent  to  the  granulations 
which  siuTound  the  ducts  and  fill  in  the  folds  of  the  mucosa,  especially 
the  prostatic  fossettes. 

In  cystourethroscopy  the  effort  is  made  to  explore  the  neck  of  the 
bladder  both  within  the  viscus  and  over  the  surface  of  the  muscle, 
in  collaboration  with  cystoscopy. 

Cystoscopy  is  fully  considered  in  Chapter  XIII,  but  must  be  here 
mentioned  on  the  broad  basis  of  including  at  the  same  sitting  the  five 
zones  of  the  bladder  described  by  the  author^  as  the  ureterotrigonal, 
subperitoneal,  urachal,  retropubic  and  cervical,  with  both  the  exami- 
nation telescope  and  retrovision  telescope. 

Inasmuch  as  the  prostate  surrounds  the  neck  of  the  bladder  entirely 
no  portion  of  the  surface  of  the  bladder  near  the  neck  must  be  omitted 
from  the  examination.  Its  limitations  during  prostatic  disease  of 
urethral  origin  in  the  strict  sense  duplicate  those  already  noted  in 
urethroscopy  in  the  preceding  paragraphs  and  involve  recognition 
of  the  fact  that  congestion  of  the  trigonum  is  the  only  sign  which  the 
bladder  may  give  and  varies  in  degree  with  the  severity  of  the  pros- 
tatic invasion  from  congestion  to  suppuration.  Thus  it  cannot  be 
regarded  as  a  part  by  itself  of  final  diagnostic  value.  The  dangers  of 
urethroscopy  and  cystoscopy  during  a  urethritis  are  the  same  as  those 
of  penetrating  these  regions  with  any  other  instrument,  with  the  added 
advantage,  however,  that  the  sheath  of  these  inspection  instruments 
always  permits  thorough  lavage  of  the  bladder  and  m-ethra;  but  this 
does  not  correct  the  likelihood  of  intensifying  a  mild  acute  luethritis, 
and  of  lighting  up  a  subacute  and  declining  stage,  solely  by  the  presence 
of  a  mechanical  device  in  the  inflamed  and  weakened  passage.  Thus 
it  is  that  in  chronic  m-etlu^itis  these  instruments  find  their  first  and 
most  advised  field  of  usefulness  so  that  one  may  wisely  say  that  the 
other  means  of  clinical  diagnosis  are  sufiicient  for  all  practical  pur- 
poses in  acute  disease  of  the  prostate,  because,  as  in  the  m-ethra,  violent 
disturbance  in  the  gland  may  follow.  A  congestion  may  be  converted 
into  an  infection  and  a  superficial  folliculitis  advanced  to  an  abscess. 
When  in  doubt  it  is  safe  to  omit  these  special  investigations  and  to 
rely  only  on  data  clinically  obtained. 

Roentgenology  as  related  to  prostatic  conditions  is  fully  discussed 
in  Chapter  XVII,  on  Diseases  of  the  Prostate  on  page  951.  ^lani- 
festly  it  is  more  suitable  for  hypertrophy  and  allied  diseases  than  for 
inflammation. 

Seminal  Vesicles. — Anatomy. — The  seminal  vesicles  are  at  each 
angle  of  the  prostate  gland  and  are  the  outermost  and  highest  of  the 
three  structures  near  this  point,  which  from  without  inward  are  the 
seminal  vesicle,  the  ampulla  of  the  vas,  and  between  these  two  at  a 
slightly  higher  level  than  their  outlets  into  the  prostate,  the  ureter. 
The  vesicle  extends  as  a  rule  higher  than  the  implantation  of  the 
ureter  into  the  bladder.    The  normal  seminal  vesicle  is  not  palpable 

1  Loc.  cit. 


442  CEXERAL  PRIXCIPLES  OF  DIAGXOSIS 

excoptins:  on  a  full  bladder — a  condition  which  should  be  presented 
by  the  patient  or  produced  by  the  surgeon  before  proceeding.  It  is  a 
soft,  wonnlike  mass  not  within  reach  until  after  the  prostate  has  been 
passed  and  then  best  by  touching  the  ])elvic  wall  first  and  sweeping 
the  finger  inward  until  its  prominence  is  detected  and  then  by  traveling 
up  and  down  along  this  over  the  entire  organ.  As  in  the  prostate  the 
examining  finger  should  detect  general  or  circumscribed  enlargement, 
nodulations,  and  other  irregularities  of  outline  and  surface,  and  changes 
in  the  density,  such  as  hardness,  bulging,  pulsation,  fluctuation  and 
involvement  with  the  perivesicular  structures. 

Pathology. — As  in  the  prostate  the  vesicles  may  show:  (1)  congestion 
of  \'arying  degrees;  (2)  suppm-ation  without  occlusion  and  with  drainage 
or  with  occlusion  and  without  drainage  and  (3)  perivesicular  involve- 
ment. 

Technic  of  Examination. — The  seminal  vesicles  become  important 
and  the  indications  of  examination  great  diu-ing  a  m-ethritis  through 
their  close  relation  with  the  urethra,  by  their  ducts  which  enter  the 
canal  within  the  body  of  the  colliculus,  where  they  are  ordinarily 
^'isible  to  close  inspection  and  where  continuity  of  the  mucosa  from 
the  urethra  along  the  duct  and  into  the  seminal  vesicle  renders  the 
transit  of  the  infecting  organism  easy.  Such  are  the  general  anatomical 
indications  while  the  histological  conditions  of  these  sacs  render  relief 
of  profound  disease  most  difficult.  Therefore  prevention  through  early 
examination  and  diagnosis  is  essential  when  possible. 

The  postm-es  are  as  in  rectal  examination  of  the  prostate  by  first 
choice  the  standing-and-stooping  attitude;  but  the  others  may  be 
employed,  such  as  the  lithotomy  and  the  lateral  positions,  although 
they  do  not  so  readily  permit  collection  of  the  laboratory  specimen. 
The  prehminaries  are  the  same  as  those  given  for  prostatic  massage 
but  will  bear  repeating  for  clearness  and  emphasis:  (1)  the  seven- 
glass  test  of  the  author  for  thorough  diagnosis  of  the  condition  within 
the  urethra  itself;  (2)  a  full  bladder  presented  by  the  patient  or  pro- 
duced by  the  operator;  (3)  evacuation  of  this  distention  to  still  further 
clean  the  m'ethra;  (4)  irrigation  of  the  anterior  and  posterior  m-ethra, 
provided  the  seven-glass  test  has  not  been  done  and  (5)  distention  of 
the  bladder  with  sterile  normal  salt  solution  which  in  evacuation  will 
wash  the  products  of  massage  of  the  seminal  vesicles  out  of  the  urethra 
and  into  the  sterilized  receiving  bottles. 

The  precautions  do  not  vary  from  those  stated  for  prostatic  work 
in  the  previous  paragraphs  and  embrace  syncope,  failure  of  diagnosis 
by  not  carrying  out  the  preluninary  preparations,  as  stated,  trauma 
by  carelessness  and  roughness  in  manipulation,  infection  of  the  bladder 
by  direct  contact  and  systemic  reaction. 

Methods  of  Examination. — There  are  commonly  two  forms:  (A) 
clinical  and  standard  and  (B)  special  and  corroborative. 

(Aj  Clinical  or  standard  examination  has  the  following  steps: 

(1)  Kectal  examination. 

(2)  Massage. 

(3)  Laboratory  examination. 


PHYSICAL  EXAMINATION  443 

(B)  Special  or  corroborative  examination  involves  only  one  step: 

(1)  Urethroscopy. 

(2)  Roentgenology. 

The  technic  of  each  of  the  foregoing  procedures  is  as  follows:  'J'here 
is  no  essential  difference  between  tlu;  prostate  and  the  seminal  vesicles 
so  far  as  rectal  examination  of  each  is  concerned,  so  that  under  the 
former  subject,  as  just  outlined,  the  reader  may  obtain  all  the  data  of 
preparation  of  the  patient,  protection  and  position  of  the  examiner, 
posture  and  procedure  for  the  systematic  palpation  of  each  of  the  seed 
sacs.  It  is  well  to  remember,  however,  the  three  pathologic  conditions 
ordinarily  found : 

1.  Seminal  vesiculitis  without  occlusion  and  with  drainage;  (2) 
seminal  vesiculitis  with  occlusion  and  without  drainage  and  (3)  peri- 
vesicular  infection.  The  laboratory  specimen  is  best  received  into 
sterilized  funnel  and  bottle  to  prevent  handling,  as  with  graduate  and 
then  funnel  and  bottle.  Specimen  No.  1  is  secured  by  allowing  the 
contents  of  the  urethi'a  to  drip  into  the  receiver  and  is  possible  only 
when  there  is  no  occlusion  of  the  ducts.  Specimen  No.  2  and  later 
may  be  obtained  by  allowing  the  patient  to  evacuate  the  fluid  within 
his  bladder  into  the  desired  nmnber  of  bottles.  Separated  specimens 
may  be  obtained  by  massaging  one  vesicle  at  one  visit  and  the  second 
sac  at  a  later  visit  or  by  going  through  the  preliminar}^  steps  after  the 
first  viscus  has  been  emptied.  The  prostate  must  not  be  touched  in 
such  a  separation  massage.  The  laboratory  investigator  takes  smear 
and  cultm-e  tests  from  as  many  specimens  as  necessary  to  reach  a 
diagnosis  and  must  regard  the  shreds  and  slugs  of  mucus,  mucopus  or 
pus  and  the  presence  or  absence  of  gonococci  and  other  infecting 
organisms.  Spermatozoids  are  commonly  best  recovered  in  the  living 
state  in  specimen  No.  1,  as  the  fluid  in  the  bladder,  especially  if  boric 
acid  water,  rapidly  kills  them.  It  is  needless  to  say  that  inquiry  must 
be  made  before  attempting  to  secure  a  specimen  as  to  whether  or  not 
the  patient  has  had  coitus  or  a  nocturnal  emission  wdthin  twenty-four 
hours.  Vesicles  thus  emptied  do  not  permit  a  satisfactory  examination, 
which  in  either  of  these  events  should  be  postponed  for  a  few  days. 

The  clinical  factors  deduced  from  such  an  examination  follow: 
(1)  normal  vesicles  are  palpable  not  at  all  or  \vdth  difficult}^;  (2)  enlarge- 
ment, unilateral  or  bilateral ;  (3)  nodulation,  general  or  local,  single  or 
multiple;  (4)  irregularity  of  form,  associated  with  perivesicular  disease; 
(5)  density,  elasticity  and  tension,  due  to  infiltration  or  abscess;  (6) 
outflow  or  dripping  from  the  m'ethra  in  cases  without  occlusion  and  with 
drainage;  (7)  no  outflow  from  the  canal  in  sacs  with  occlusion  and  with- 
out drainage  or  in  vesicles  emptied  by  physiological  action;  and  (8) 
pain  and  sensitiveness  even  on  gentle  pressure.  As  stated  m  the 
paragraphs  on  the  prostate  on  page  314,  cases  without  drainage  will 
sometimes  declare  themselves  by  waitmg  for  the  occlusion  to  be  cured 
by  Nature  or  by  treatment. 

The  microscopic  features  are  the  epithelium  from  the  lining  of  the 
ducts  and  the  sac,  blood  cells,  pus  cells  and  mucus,  spermatozoa 


444  GEXERAL  PRIXCIPLES  OF  DIAGXOSIS 

living  or  dead,  and  the  gonococci  or  other  organisms.  Germs  of  infec- 
tion other  than  tlie  gonoeoceus  are  extremely  imj)ortant  and  should 
always  be  looked  for  in  eases  of  so-ealle<l  gonoeoecal  arthritis,  because 
the  streptococcus  and  its  allies  are  a:-  fretiuently  the  cause  of  such  joint 
in^'ol^'ement  as  the  gonococcus  and  unless  the  exact  nature  of  the 
infection  is  determined,  serotherapy  with  the  wrong  organisms  as  its 
basis  will  be  a  failure  and  sometimes  a  danger. 

I'rethroscopy  and  its  ai)])lication  to  the  Seminal  Vesicles  are  fully 
discussed  in  Chapter  XII  and  Cha])ter  V,  on  the  Complications  and 
Sequels  of  Chronic  Urethritis  on  page  321,  in  the  notes  on  the  work  of 
Thomas  and  Pancoast.  These  authors  were  among  the  first  in  the 
United  States  to  inject  the  vesicles  witli  prei)arations  oi)aque  to 
the  .r-ray. 

LABORATORY  EXAMINATION. 

General  Importance. — The  de\'elopment  of  all  laboratory  in\'estiga- 
tion  in  medicine,  as  a  science  antl  an  art,  has  been  so  great  within  the  last 
few  years  that  this  department  of  diagnosis  cannot  be  omitted  advisedly 
in  any  conscientious  service  of  the  patient.  Precisely  as  the  laboratory 
expert  aids  in  the  diagnosis  of  the  clinician  by  furnishing  all  the  ele- 
ments therein  which  he  can  supply,  so  should  the  clinician  without 
reserve  give  to  the  laboratory  worker  all  the  facts  within  his  knowledge, 
so  that  his  conclusions  may  take  due  account  of  the  clinical  aspect  of 
the  case.  It  is  certainly  an  error  in  judgment  to  hand  a  laboratory 
specialist  a  bare  specimen  without  comment  and  exj)ect  him  to  give  a 
final  opinion.  If  such  knowledge  is  regarded  as  likely  to  compromise 
the  independence  of  such  opinion,  then  another  laboratory  man  should 
be  selected,  who  cannot  be  thus  biased. 

It  is  therefore  necessary  to  supply  to  the  laboratory  the  main  and 
broad  facts  of  the  subjecti\'e  history,  the  objective  observation  and 
examination  and  the  suggested  clinical  diagnosis. 

In  urological  investigations  the  specimens  are  usually  obtained 
among  the  first  essentials  of  the  case,  but  this  subject  is  considered  in 
this  part  of  this  chapter  after  physical  examination  and  special  local 
examination,  in  order  to  conform  with  the  fact  that  the  results  of  the 
laboratory  work  are  usually  considered  after  such  clinical  knowledge 
has  been  obtained.  On  account  of  its  importance  urethral  discharge 
of  any  character  must  be  investigated  by  smear  and  culture,  the  urine 
analyzed  for  the  same  products  of  infection  and  for  signs  of  essential 
or  complicating  disease  in  the  upper  urinary  tract  and  the  blood  test 
must  be  performed  for  the  gonococcal  complement  fixation  as  estimate 
of  the  condition  of  chronic  cases.  The  general  aims  of  examination  are 
more  fully  discussed  in  the  oi)ening  jxiragraphs  of  this  chapter. 

Examination  of  Discharge. — Definition.  —  Any  abnormal  urethral 
product,  ^^•llctllcr  us  free  jjus  or  as  shreds  appearing  in  the  urine  only, 
must  clinically  be  regarded  as  discharge. 

Varieties. — From  this  statement  it  w'ill  be  realized  that  the  varieties 
are  two:  (1)  free,  which  is  copious  and  wdll  infect  the  clothing,  genitals 


LABORATORY  EXAMINATION  445 

and  thighs  unless  a  suitable  dressing  is  worn  and  (2)  masked,  which  is 
not  apparent  externally  at  all  but  appears  only  in  the  urine  as  shreds 
and  masses  of  pus  which  must  be  washed  out  either  by  the  urinary 
stream  or  by  irrigation  with  a  syringe.  The  free  discharge  should  be 
settled  as  to  its  source  either  from  the  urethra  or  from  the  foreskin, 
by  the  subjective  statements  of  the  patient  concerning  ardor  urinee 
and  by  objective  examination  including  washing  of  the  meatus,  retrac- 
tion of  the  foreskin  and  study  of  all  its  recesses.  This  retraction  must 
be  thorough  because  it  often  happens  that  until  the  last  folds  are 
smoothed  out  the  source  of  the  pus  remains  undetected.  A  balano- 
posthitis,  as  explained  under  this  complication  on  page  94,  may  be 
simple,  purulent,  verrucous,  chancroidal,  chancrous  and  finally  ulcerous 
and  any  of  these  varieties  may  produce  little  or  much  discharge,  whose 
source  must  be  known  and  precise  bacteriologic  factors  determined 
before  one  may  wisely  proceed.  Where  retraction  of  the  foreskin  cannot 
be  performed,  through  edema  or  infiltration  a  Chetwood  urethroscope 
may  be  passed  through  it  and  then  made  to  explore  the  cavity  thor- 
oughly, with  the  obvious  disadvantage  that  very  little  of  the  cavity 
of  the  foreskin  may  be  seen  at  one  time  and  that  the  field  is  constantly 
flooded  with  excess  of  pus,  unless,  as  should  always  be  done,  subpre- 
putial  irrigation  is  previously  carried  out.  After  such  cleansing  the 
urethroscope  may  be  more  readily  employed  and  sometimes  without 
it  the  urethra  may  be  seen  to  be  the  source  of  discharge,  but  the  fore- 
skin might  in  such  a  case  of  phimosis  remain  yet  to  be  diagnosticated. 

The  irrigation  of  the  foreskin  is  very  well  carried  out  with  the 
Valentine  nozzle,  shield  and  cutoff,  with  a  female  catheter  mounted 
according  to  the  author's  method,  as  shown  in  Fig.  18  on  page  86. 
This  device  permits  irrigation  from  the  deepest  recesses  of  the  foreskin 
outward  and  under  sufficient  pressure  to  balloon  the  foreskin  as  a 
whole  and  thus  add  to  the  hydraulic  cleansing.  Or  the  hand  bladder 
syringe  and  short  rubber  catheter  may  be  used.  The  patient  may  be 
given  the  Acme  subpreputial  syringe  shown  in  Fig.  7  on  page  49,  for 
use  at  home. 

Free  Discharge  of  Balanoposthitis. — The  form  varies  as  follows:  (1) 
the  simple  type  has  mucopus  with  a  characteristic  odor,  and  with  only 
superficial  chafing  of  the  lining;  (2)  the  purulent  form  has  copious 
pus  in  the  strict  sense,  also  characteristic  odor  and  usually  local  or 
universal  more  or  less  deep  erosion  of  the  surface,  and  is  seen  in  gono- 
coccal and  its  mixed  infections  and  in  verruca;  (3)  chancroidal  lesions 
vary  so  widely  in  their  penetration  of  the  surface  as  to  make  description 
here  out  of  place  but  their  discharge  is  mucopurulent,  purulent  and 
sanguineous  according  to  severity  and  (4)  chancrous  manifestations 
belong  to  the  same  complex  type  with  a  discharge  which  is  serous, 
seropurulent,  purulent  and  even  sanguineous  according  to  severity 
and  destructiveness.  Only  a  careful  clinical  and  bacteriological  investi- 
gation will  distinguish  these  forms  from  each  other. 

Free  Discharge  of  Urethritis. — Scientific  diagnosis  requhes  the  fol- 
lowing factors  to  be  known,  in  addition  to  bacteriology:     Cause, 


446  GEXERAL  PRIXCIPLES  OF  DIAGNOSIS 

ocx^uiTcnce,  quantity,  color,  odor  ami  coiisistoncc.  The  cause  may  be 
chemical  from  strong  hand  injections  taken  in  self-cure,  or  an  infection 
from  without  the  body  in  the  venereal  sense  or  from  within  the  body 
in  the  systemic  sense,  or  from  functional  disorder  as  in  relaxation  of 
the  prostate.  The  occurrence  may  be  persistent  throughout  the  day 
and  night,  raj^idiy  recurring  after  the  urine  has  cleansed  the  urethra, 
or  intermittent  through  the  declining  stage  of  a  general  urethritis  or 
through  the  evacuation  of  minute  or  large  abscesses  in  the  mucosa 
itself  or  in  the  prostate,  as  examples.  The  (juantity  \aries  widely  and 
is  couAcniently  estimated  in  terms  of  the  number  of  dressings  necessary 
in  the  day  in  cases  with  continuous  discharge,  exactly  as  one  estimates 
menstrual  flow  in  terms  of  the  napkins  used.  Or  the  quantity  may  be 
mere  drops  at  frequent  intervals  through  the  day  or  only  in  the  morning 
as  the  "morning  drop,"  or  crusts  and  gum  at  the  meatus  dependent 
on  the  rate  with  which  evaporation  and  drying  occur,  or  finally  mere 
shreds,  flakes  and  floaters  in  the  urine  alone  without  external  mani- 
festations. Another  estimate  of  the  free  pus  in  continuous  discharge 
is  furnished  by  the  number  of  discolored  glassfids  voided  in  the  various 
multiple  glass  tests  as  hereinafter  discussed.  The  color  may  be  the 
yellow  or  greenish-yellow  of  true  gonococcus  infection,  whitish  or  yel- 
lowish-white of  the  pyogenic,  gra^'ish  to  blue  from  the  Bacillus  pyo- 
cyaneus,  whitish  and  viscid,  much  like  oyster  juice,  from  seminal  and 
jjrostatic  fluid  and  Avatery  and  sticky  like  glycerin  in  mucous  and 
catarrhal  conditions.  The  odor  is  that  of  smegma  in  balanoposthitis 
and  fishy  in  seminal  elements,  but  odor  is  commonly  absent  in  the 
majority  of  m-ethral  discharge.  The  consistency  varies  greatly.  It 
is  thick  like  thin  honey,  or  thin  and  watery  like  diluted  milk,  according 
to  circiunstances  of  the  admixture  of  seriun  with  it.  It  may  be  uniform 
in  consistence  or  filled  with  masses,  shreds  and  flakes,  like  driftwood 
in  a  bay.  It  may  dry  readily  on  the  clothing  with  or  without  stain  or 
remain  thick  and  gummy.  These  latter  characteristics  are  important 
in  women  in  whom  commonly  the  normal  mucus  from  the  A'agina  does 
not  stain  or  stick.  It  may  be  so  thick  as  to  form  a  gum  at  the  meatus 
because  it  does  not  evaporate,  or  become  a  crust  through  exactly  the 
opposite  circumstance,  so  that  a  scab-like  mass  must  be  broken  by 
the  urine  or  the  fingers  before  any  discharge  within  the  meatus  may  be 
recovered. 

Bacteriology. — Bacteriology  of  the  genital  apparatus  in  both  sexes  is 
highly  varied  in  both  health  and  disease  and  a  partially  complete  list 
of  the  various  organisms  encountered  is  shown  in  the  paragraphs  on 
nongonococcal  bacterial  lu-ethritis  in  the  Chapter  on  Acute  Urethritis 
and  in  the  paragraphs  of  this  chapter  noting  the  bacteriolog}''  of  the 
urine,  respectively,  on  pages  22  and  4(59. 

The  bacteriology  is  beyond  question  the  most  important  of  all 
characteristics  of  the  discharge  and  is  determined  by  smear,  culture 
and  inoculation  as  set  forth  in  the  sections  on  Acute  and  Chronic 
Urethritis  on  pages  25  and  205,  and  those  on  Tuberculosis  on  page 
131.    The  smear  is  obtained  by  first  thoroughly  cleansing  the  foreskin 


LABORATORY  EXAMINATION  447 

and  meatus  with  a  sterile  gauze  or  cotton  sj)onge  rnoistencsfl  in  an 
antiseptic,  such  as  boric  acid  water.  The  methods  are  with  two  slides, 
cotton  swab  and  slide  and  platinum  loop  and  slide, 

1.  Tioo-slide  Method. — A  drop  of  the  free  dis(;harge  is  then  gently 
stripped  from  the  urethra  or  allowed  to  drop  of  itself  upon  one  end 
of  a  microscopic  slide,  suitably  j)repared  and  sterilized.  The  edge  of 
another  similarly  prepared  slide  is  laid  across  the  far  end  of  this  deposit 
and  then  drawn  with  only  its  own  weight  evenly  along  the  slide  from 
end  to  end,  thus  wiping  the  drop  out  into  a  very  thin  "smear."  The 
technic  is  exactly  that  followed  in  the  preparation  of  blood  for  staining 
and  microscopy. 

2.  Swab  and  Slide  Method. — If  the  discharge  is  less  copious,  then  a 
cotton  swab  on  a  toothpick,  singed  in  the  flame,  may  be  passed  into 
the  urethra  for  an  inch  or  more,  rotated  gently  in  order  to  gather  up 
as  much  pus  as  possible  and  then  withdrawn  and  passed  along  a  slide 
from  end  to  end  exactly  like  a  whitewash  brush  and  thus  produces 
a  thin  smear.  One  hardly  ever  finds  a  patient  intelligent  enough  to 
prepare  smears  himself,  in  both  the  details  of  sufficient  thinness  and 
absence  of  contamination;  such  specimens  should,  therefore,  be  always 
prepared  by  the  urologist  himself  or  a  suitably  trained  attendant. 

3.  Platinum  Looy  and  Slide  Method. — If  the  discharge  is  still  less  as 
in  chronic  cases  after  the  preparation  of  the  patient  and  slides  as  just 
stated,  a  platinum  loop  is  flamed  red  hot,  cooled  and  while  the  meatus 
is  held  open  by  the  patient  or  the  surgeon  without  having  touched  its 
lips,  the  loop  is  passed  edgewise  into  it  and  along  the  roof  of  the  canal 
for  an  inch  or  more  with  great  gentleness  so  as  not  to  cause  bleeding. 
At  this  point  it  is  turned  breadthwise  and  withdrawn  along  the  floor 
of  the  canal  as  a  blunt  curette,  scooping  in  its  course  whatever  pus  and 
detritus  are  present  and  should  emerge  with  its  loop  and  shaft  covered. 
Such  collection  is  then  deposited  on  a  slide  and  with  the  wire  itself 
teased  and  streaked  into  a  smear. 

The  fixation  of  a  smear  may  be  done  with  heat  but  equally  well  and 
more  rapidly  by  flooding  the  slide  with  equal  parts  of  95  per  cent, 
ethyl  alcohol  and  anesthesia  ether  and  allowing  them  to  evaporate. 
This  simple  step  never  spoils  the  specimen  by  overheating,  requires 
no  watching  and  may  be  done  in  the  mailing  box  just  before  sending 
it  to  the  laboratory. 

The  culture  of  urethral  discharge  is  more  important  than  the  smear 
alone  and  should  always  be  undertaken  as  the  essential  part  of  this 
element  in  the  diagnosis,  because  the  culture  essentially  involves 
smear  examinations  later.  This  might  be  called  the  platinmn  loop 
culture  medium  and  smear  method.  The  patient  is  prepared  exactly 
as  for  taking  a  smear  with  the  loop  just  described  in  the  preceding 
paragraphs.  The  specimen  on  the  wire  is  gently  streaked  along  the 
slant  culture  in  the  tube  which  is  immediately  sealed  with  the  cotton 
plug  and  then  in  the  writer's  preference  this  is  singed  and  covered  with 
sterile  gauze  secured  by  an  elastic  to  the  top  of  the  tube.  The  clinical 
report  for  the  laboratory  is  folded  around  and  fastened  to  the  tube 


448  GENERAL  PRIXCIPLES  OF  DIAGNOSIS 

witli  a  narrow  ])ioce  of  adllesi^•o  plaster,  below  the  label  for  laboratory 
monioraiula. 

At  least  three  tubes  should  be  taken  at  each  sitting,  of  which  one, 
labelled  Avith  the  patient's  name,  should  be  kept  at  room  temjierature 
in  the  lu'ologist's  office  and  known  as  the  control  tul>e.  The  other  two 
tubes  arc  kci)t  in  an  incubator  at  blood  tem])craturc  until  called  for  by 
the  laboratory,  whose  messenger  should  carry  them  in  his  inside  pocket 
close  to  his  body  in  order  to  prevent  any  fall  in  temperature  which 
always  kills  the  gono.-occus,  or  makes  it  grow  imperfectly. 

The  control  tube  at  room  tcmjwraturc  will  show  abundant  growth 
of  the  ^licrococcus  catarrhalis  and  other  organisms  if  present,  but 
not  of  the  gonococcus.  If,  therefore,  the  laboratory  reports  gonococci 
absent  and  the  nature  of  the  other  organisms  in  doubt,  the  presence  of 
such  growth  in  the  control  tube  is  strong  evidence  but  not  absolute 
proof  of  the  catarrhal  nature  of  the  lesion.  All  culture  of  the  m-ethral 
discharges  for  the  gonococcus  rests  on  special  culture  media  as  discussed 
in  Chapter  I  on  Acute  Urethritis  on  page  26,  and  has  its  basis  only 
in  media  containing  serum  from  blood,  hydrocele  fluid  or  peritoneal 
effusion. 

A  specimen  report  form  of  conAcnient  arrangement  is  the  following 
in  assisting  the  urologist  to  include  all  the  data  essential  to  proper 
judgment  of  the  case  by  the  bacteriologist. 

Clinical  Notes  Concerning  Specimen 

•  Name Date 

Ward  room   History    No 

Nature  of  specimen 

Where  obtained 

How  obtained 

What  is  requested 

Remarks   


Clinical  diagnosis Ser\'ice  of  Dr. 

Patient  of  Dr. 


Frequent  transplantation  from  the  culture  tube  to  Petrie  dishes 
must  be  made  before  a  final  separation  of  the  various  organisms  present 
may  ])e  made.  This  fact  should  be  explained  to  patients,  otherwise 
the  delay  in  the  report  which  this  procedure  necessitates  will  lead  to 
discontent. 

Inoculation  of  animals  as  a  diagnostic  aid  in  urethritis  is  far  less 
valuable  than  in  diseases  of  the  bladder,  ureters  and  kidneys  and  is 
therefore  much  less  frequently  applied  in  the  former  than  in  the  latter; 
but  it  may  be  reserved  for  difficult  and  obscure  cases  as  determined 
by  the  wish  of  the  laboratory  experts. 

Repetition  of  Tests. — Smears,  culture  and  inoculation  are  the  diagnostic 
stei)s  wliicli  ])crniit  the  urologist  to  determine  the  course  of  the  disease, 
which  is  measured  by  the  slow  disa])pearance  of  the  organisms  in  pure 
or  mixed  culture  and  finally  of  the  products  of  active  pus-formation. 


LABORATO/iY  EXAMINATION  449 

The  urologist  should,  therefore,  he  prepared  to  make  rather  frequent 
observations  in  every  ease  as  the  measure  of  his  treatment  and  not  be 
satisfied  with  the  initial  diagnosis  alone,  no  matter  how  completely 
made.  Before  the  patient  is  released  from  treatment  a  thorough 
bacteriologieal  diagnosis  must  be  made. 

The  complement  fixation  test  for  gonorrhea,  while  a  very  reeent  dis- 
covery, is  of  great  importance  and  should  always  be  employed  before 
the  patient  is  discharged  from  treatment.  Its  final  interpretation  is 
still  to  be  fixed  by  experience,  but  several  authorities  regard  it  as  one 
of  the  determinators  of  marriageability,  in  the  effort  to  avoid  obscure 
sources  of  infection.  It  is  generally  believed  that  patients  who  have 
had  gonococcal  infection  for  a  long  period  or  with  profound  complica- 
tions show  this  test  in  various  positive  degrees,  and  that  patients  who 
have  reached  a  speedy  cure  and  without  complications  show  it  either 
not  at  all  or  only  in  slight  and  temporary  degree. 

Masked  Discharge  of  Urethritis. — Filaments,  also  known  as  shreds, 
threads  and  flakes,  are,  as  already  described,  that  discharge  which  is 
not  copious  or  free,  does  not  get  upon  the  body  or  clothing  and  exists 
chiefly  within  the  urine.  Its  importance  rests  on  the  element  of  diag- 
nosis discussed  in  the  opening  paragraph  of  this  chapter,  as  the  per- 
sistence of  infection.  The  diagnosis  of  these  shreds  in  full  detail, 
therefore,  involves  the  recognition  of  whether  or  not  the  patient  is 
without  infection  and  will  not  transmit  the  disease  to  the  marriage 
bed  and  through  this  to  the  eyes  of  offspring.  The  details  of  diagnosis 
must  include  recognition  of  the  soiuce,  number,  size,  density,  buoyancy, 
consistency  of  the  threads  and  the  character  of  the  urine  in  which  the 
threads  appear.  In  brief,  macroscopic  and  microscopic  examination 
of  the  mass  discharged  is  absolutely  necessary  and  will  respect  the 
following  broad  facts: 

Macroscopic  Examination. — 1.  As  to  source,  the  threads  may  come 
from  any  portion  of  the  mucosa,  the  essential  glands  of  the  mucosa, 
or  the  sexual  glands  or  their  ducts  emptying  into  the  luethra.  They 
may  arise  by  the  process  of  exfoliation  at  various  spots  of  the  lining 
of  the  urethra  or  any  of  the  acini  or  ducts  of  the  glands  or  by  the . 
thickening  of  normal  secretion  into  plugs  which  are  throwai  out  by  the 
glands.  The  process  is  the  same  in  kind  but  different  in  degree  if  the 
sexual  glands  are  the  source. 

2.  As  to  depth  of  origin,  the  flakes  may  as  just  indicated  be  super- 
ficial or  deep,  so  that  casual  examination  is  an  injustice  to  the  patient, 
because  it  involves  merely  inspection  of  the  meatus  and  perhaps  urine 
and  often  release  of  the  patient  from  treatment  long  before  the  deeper 
parts  of  the  mucosa  have  been  freed  of  infection. 

3.  As  to  number,  the  filaments  may  be  very  few  so  as  to  make  close 
study  of  the  specimen  of  m"ine  necessary,  or  so  niunerous  as  to  be  easily 
observed  and  described  by  the  patient  himself. 

4.  As  to  size  and  form,  the  shreds  may  be  long  and  threadlike,  short 
and  hoodlike  (comma  shreds)  or  long  and  thick,  much  like  masses  of 
nasal  mucus,  occm-ring  in  lumps  and  clumps. 

29 


450 


GEXERAL  PRIXCIPLES  OF  DIACXOSIS 


5.  As  to  density,  consistency  and  buoyancy,  tlio  flakes  may  float 
readily  about  the  upj^er  layer  of  the  lu-ine  in  which  the\'  slowly  dissolve, 
or  they  may  sink  with  p-eat  rapidity  and  remain  at  the  bottom  of  the 
glass  unless  distm-bed  by  shaking. 

6.  As  to  color,  the  nuicous  shreds  are  transi)arcnt  and  almost 
watery,  or  fllled  with  flne  whitish  s])ots  throughout  their  rather  exten- 
sive mass  and  the  i)us  shreds  are  oi)aque  antl  whitish-yellow   or  yellow. 

The  mucous  and  })us  filaments,  in  recapitulation,  nia>'  be  said  to 
difl'er  in  the  following  details:  (1)  The  mucous  sjXH'imens  are  a  few, 
large,  cloudlike,  light,  floating  masses  usuall\'  without  infectious 
elements,  often  containing  in  their  midst  ])atches  of  shed  epithelium. 
In  general  they  represent  the  last  few  weeks  of  catarrh  following  the 
suppurative  urethritis.  'I'he  urine  is  commonly  clear.  (2)  The  piu-ulent 
sj^ecimens  are  usually  many  small  or  large  of  any  ordinary  form, 
heavy,  sinking  to  the  bottom  and  ])ossessing  organisms,  whose  character 
nuist  be  known.  The  urine  may  be  slightly  purulent  or  clear.  In 
general  they  rei)resent  an  uncured  case  with  minor  or  major  complica- 
tions. 

Multiple  Glass  Tests.  —  Classes. —  ]Multii)le  glass  tests  are  divided 
into  thi-ee  groups:  (a)  those  without  irrigation  and  without  dyes, 
•among  which  the  most  prominent  are  the  Thomi)son  two-glass  test 
and  the  Luy's  four-glass  test  and  (b)  those  with  irrigation  and  without 
dyes,  among  Avhich  the  best  are  Wolbarst's  five-glass  test,  the  author's 
seven-glass  test.  Kollman's  five-glass  test  and  Young's  se\'en-glass  test, 
and  (c)  those  with  irrigation  and  with  dyes,  among  which  are  included 
as  the  choice,  Krohmeyer's  and  Lohnstein's. 

General  Principles. — Before  discussing  each  it  is  well  to  understand 
the  broad  facts  of  the  quality  of  the  urine  obtained  and  the  meaning 
of  the  ste])s  in  securing  it.  The  quality  of  the  urine  may  be  clear  or 
tm-bid.  The  former  condition  permits  ready  examination  of  foreign 
elements,  but  the  turbidity  must  be  tested  as  it  need  not  depend  on  pus 
alone.  Hayden^  gives  the  following  meanings  of  cloudy  urine  under 
such  investigation  after  Ultzmann.'  "By  gradually  heating  the  upper 
half  of  the  urine  (in  a  test-tube)  to  boiling,  the  opacity. 


Vanishes. 


Increases. 


Remains  unchanged  even 
after  addition  of  acetic 
acid. 


If    due    to 
acid 
urates. 


If  due  to  earthy  phosphates,  carbonates  or  pus- 
corpuscles.  Add  one  or  two  drops  of  acetic 
acid. 


Dimness  van- 
ishes with 
evolution  of 
gas ;  carbon- 
ates. 


Dimness  van- 
ishes without 
evolution  of 
gas;  phos- 
phates. 


Dimness  re- 
mains un- 
changed ;  pus. 


The  dimming  is  caused 
by  catarrhal  secretion, 
or    by    bacteria. 


'  Venereal  Diseases,  '.id  edition,  p.  28. 

'  Ultzmann,  Vorlesungen  iiber  Kraakheiten  d.  Harn.,  1892,  p.  3. 


LABORATORY  EXAMINATION  451 

The  general  basis  of  the  multiple  glass  tests  should  be  thoroughly 
comprehended  after  the  quality  of  the  urine  has  been  settled,  and 
embraces  the  following  general  details:  (1)  The  cavity  of  the  urethra 
should  be  flushed  clean  with  the  urine  or  with  artififiul  rn(;ans,  in  the 
anterior  urethra  first.  (2)  The  posterior  portion  must  likewise  be 
flushed  clean  by  either  or  both  means.  (3)  It  will  be  noticed  at  once 
that  the  urine  of  itself  cannot  flush  the  urethra  except  from  the  neck 
of  the  bladder  forward,  and,  therefore,  carries  with  and  before  it  much 
that  is  in  the  posterior  urethra  into  the  anterior  urethra,  so  that  it  is 
not  possible  after  micturition  to  state  with  absolute  certainty  the 
source  of  shreds  or  pus.  (4)  Unless  the  patient  has  about  five  hours' 
urine  in  his  bladder  he  will  not  have  sufficient  for  suitable  flushing  of 
the  urethra  at  all.  (5)  These  limitations  of  natural  evacuation  make 
irrigation  of  the  urethra  an  essential  basis  of  these  four-glass  and  five- 
glass  tests  which  are  now  accepted  as  worth  while,  and  by  means  of 
irrigation  the  anterior  urethra  is  first  cleansed  with  or  without  the 
instillation  of  dyestuffs  into  it,  before  the  accumulated  pus  in  the 
posterior  urethra  is  obtained. 

Multiple  Glass  Tests  without  Irrigation  and  without  Dyes. — Thompson's 
two-glass  test^  consists  of  urination  into  two  rather  large  glasses.  Its 
fallacies  are  summed  up  in  the  following  principles: 

1.  Too  little  urine  permits  the  patient  to  wash  out  his  urethra  so 
deficiently  that  even  the  anterior  portion  is  not  properly  cleansed.  The 
first  glass  will  contain  perhaps  a  half -inch  of  urine  and  there  is  no  second 
glass. 

2.  Too  much  urine  causes  the  subject  to  wash  the  urethra  as  a  whole 
so  that  in  the  first  glass  all  the  pus  may  be  accumulated  and  the  second 
glass  be  clear  although  the  lesion  may  be  in  the  posterior  urethra. 

A  very  safe  rule  is  to  have  the  patient  call  with  about  five  hours' 
excretion  in  his  bladder.  In  most  subjects  this  supply  will  reach  about 
200  to  250  c.c.  and  furnish  two  good  specimens  and  thus  avoid  both 
fallacies  noted  above.  The  Thompson  test,  even  in  these  circumstances, 
is  only  an  index  and  not  a  diagnostic  certainty. 

Some  of  this  difficulty  is  corrected  by  having  the  glasses  of  not  more 
than  100  c.c.  capacity  (3  to  4  ounces),  which  compel  the  patient  to 
change  glasses  before  he  has  emptied  an  ordinary  bladderful  of  200  to 
250  c.c.  (6  to  8  ounces) .  Furthermore,  the  character  of  the  shreds  may 
indicate  their  source  in  anterior  or  posterior  urethra,  especially  when 
combined  with  carefully  taken  subjective  history,  objective  examination 
and,  most  important  of  all,  with  urethi-oscopy.  It  must  never  be  for- 
gotten that  pus  and  detritus  in  the  anterior  m-ethra  may  ha\'e  gravi- 
tated thither  from  the  posterior  urethra  after  the  former  is  fully  cured — 
a  diagnosis  which  is  xevy  difficult  to  make  without  the  urethroscope  as 
the  final  verifier. 

The  interpretation  or  diagnosis  rests  on  the  condition  of  the  contents 
of  the  two  glasses,  which  may  follow  these  tlu'ee  variations: 

1,  Glass  I,  cloudy;  Glass  II,  cloudy. 

'  Clinical  Lectures  on  Diseases  of  the  Urinarj'  Organs,  Sth  ed.,  ISSS,  pp.  12  and  448. 


452  GENERAL  PRIXCIPLES  OF  DIAGXOSIS 

2.  Glass  I,  cloudy  or  slightly  turbid;  Glass  II,  clear,  or  clarified  of 
phosphates  and  carbonates  by  the  steps  noted  in  the  pre\'ious  para- 
graphs and  either  or  both  filled  with  filaments  as  described. 

3.  (ilass  I,  clear;  Glass  II,  clear. 

The  accepted  indications  of  the  foregoing;  conditions  of  the  lu'ine 
in  two  glasses  follow.  If  both  glasses  are  turbid  there  may  be  present 
(either  (a)  generalized  acute  anterior  and  posterior  urethritis,  (b)  a 
purulent  lesion  of  the  bladder  and  (c)  a  i)urulent  disease  of  the  kidneys 
and  lU'ctei-s  in  either  or  both  sides. 

If  Glass  I  is  turbid  and  (ilass  II  clear,  there  is  usually  present  a 
declining  urethritis,  commonly  anterior  in  its  situation,  but  less  often 
anteroposterior,  whose  moderate  products  are  washed  into  the  first 
glass,  if  too  large  by  a  copious  flow  of  urine. 

If  Glasses  I  and  II  are  clear,  as  passed  or  as  freed  of  pliosphates  or 
carbonates  as  above,  and  contain  filaments  having  the  foregoing 
characters,  there  is  usually  present  chronic  anteroposterior  urethritis 
with  or  without  complications. 

It  will  be  noted  the  two-glass  test  is,  therefore,  incompetent  to  decide 
uncertainties,  which  have  rendered  the  artificial  cleansing  of  the  anterior 
urethra  by  irrigation  absolutely  essential  in  order  to  separate  the  pro- 
ducts in  the  two  major  segments  of  the  canal  from  each  other. 

Lily's  Fovr-glass  Tcsi.  —  lh]^  writer^  also  calls  this  the  practical 
method  and  claims  that  urination  into  four  glasses  is  usually  adequate 
for  diagnosis,  on  the  ground  that  if  the  Glass  I  has  not  cleansed  the 
anterior  urethra.  Glass  II  and  Glass  III  will  do  it  progressively.  If  the 
Glass  IV  shows  heavy  flakes  while  the  second  and  third  contain  none 
or  but  few,  posterior  urethritis  is  proved.  In  general,  therefore,  dis- 
tinction between  the  two  parts  of  the  canal,  anterior  and  posterior,  as  to 
lesions  is  given  by  Glass  II  and  Glass  III.  This  method  contains  the 
fallacy  of  almost  all  other  methods  in  omitting  investigation  of  the 
bladder  as  a  source  of  pus  and  detritus  with  the  catheter. 

Luy's  tabulation  of  diagnosis  is  in  these  terms: 

First  slass  clear  or  turbid,  with  hea\'\'  filaments;  1         f  a    j.     •  iu  -x- 

J    iu-  J        J  r       xu     1  1  -xi.  Anterior  urethritis  or  pos- 

second,  third,  and  fourth  glasses  clear,  with-  r  =  i       x    ■  ^\    ■^■ 

,  ci  X  tenor  urethritis, 

out  filaments. 

First  plass  clear  or  turbid,  with  hca\v  filaments; 

jj  I       second  and  third  glasses  clear,  without    fila-  I  _  ]  Anterior  urethritis  and  pos- 

ments;  fourth  glass  clear  or  turbid,  with  heavy  \  ~  |       terior  urethritis. 

filaments. 

(First  glass  clear,  with  a  few  hea^^  filaments; 
second  and  third  glasses  clear,  ^\•ith  a  few  or  i         i  -o     .     •  -i    -i-       u-  a 

c,  .      f       ft,     1        i     1  •  I       -xi   1  )  =  {  Posterior  urethritis  chiefly, 

no  filaments;  fourth  glass  turbid,  vnih  heavy  (        | 
filaments.  J        [ 

Multiple  Glass  Tests  with  Irrigations  and  without  Dyes. — General 
Principles. — Irrigating  multiple  glass  tests  recognize  tlie  need  of  secur- 
ing the  contents  of  the  anterior  and  posterior  urethra  and  include  the 
methods  of  Wolbarst,  Kollmann,  Young  and  the  author,  which  do  not 
use  a  dye. 

Wolharsfs  Five-glass  Test  is  a  good  one  because  it  distinguishes  the 
contents  of  the  anterior  urethra,  posterior  urethra,  bladder  and  prostate 

1  Text-book  on  Gonorrhea,  1913,  p.  90. 


LABORA  TOR  Y  EX  A  M  IN  AT  ION 


453 


with  the  seminal  vesicles  with  reasonable  accuracy.  Like  all  other 
multiple  glass  tests,  it  is  not  infallible  and  should  be  corroborated  with 
objective  examination  and  urethroscopy.  Wolbarst's  original  method 
consists  in  passing  the  catheter  into  the  bladder  after  the  anterior 
urethral  glass  and  control  glass  have  been  secured.  This  makes  the 
bladder  third  of  the  series,  but  this  method  has  the  objection  of  greater 
risk  of  infecting  the  bladder  especially  when  the  posterior  urethra  is 
rather  full  of  exudate,  either  from  its  own  mucosa  or  from  the  prostate 
and  vesicles.  The  author  has  therefore  modified  the  Wolbarst  test  to 
agree  in  this  detail  with  his  own  seven-glass  test,  which  adds  separation 
of  the  contents  of  the  prostate  and  the  right  and  left  seminal  vesicle 
severally  from  each  other  as  hereinafter  noted  and  gives,  therefore, 
still  more  thorough  indication  of  the  corldition  of  the  lower  urinary  tract 
and  its  annexed  sexual  organs  and  even  forms  a  lead  to  lesions  of  the 
bladder,  ureters  and  kidneys. 


Fig.  120. — Irrigation  for  the  anterior  urethral  glass  in  the  author's  seven-glass  test 
(original).  After  standard  drapery  (Fig.  15)  a  large  sterile  glass  is  held  by  the  strap  at 
the  upper  end  of  the  Wolbarst  basin.  The  left  hand  supports  the  catheter  within  the 
penis  and  makes  it  coil  within  the  glass.  The  right  hand  makes  the  irrigatiorh.with  a 
Janet-Frank  syringe  and  the  outflow  is  conducted  by  the  course  of  the  catheter  directly 
into  the  glass  as  shown. 

Author's  Modification  of  the  Wolbarst  Five-glass  Test.— -The  maimer 
in  which  the  writer  prefers  to  secure  the  five  glasses  of  the  Wolbarst 
test  is  as  follows : 

1 .  The  patient  must  come  with  the  bladder  as  full  as  possible,  by  hold- 
ing his  urine  for  five  hours;  the  instruments  must  be  carefully  adjusted 
and  prepared;  the  irrigation  and  massage  must  be  thoroughly  done 
and  finally  judgment  and  experience  must  be  brought  to  the  diagnosis 
of  all  the  glasses  arranged  in  a  row. 

2.  A  precaution,  antecedent  and  subsequent  to  the  test  and  never  to 
be  omitted,  is  the  administration  of  anj'^  standard  and  efficient  m-inary 
antiseptic  for  several  days.  None  is  better  than  a  solution  of  five  to 
ten  grains  each  of  benzoate  of  soda  and  of  one  of  the  formaldehyde-pro- 
ducing drugs  to  a  dram  of  water  three  or  four  times  a  day  in  a  glassful 
of  water  about  two  hours  after  eatmg. 


45-4  GEXERAl.  rii-lXCll'LES  OF  DIAdXOSIS 

3.  With  the  patient  flat  on  his  back  on  a  table,  with  shirts  rolled  up 
to  his  armpits  and  trousers  turned  down  to  his  knees  and  with  a  Wol- 
barst  basin  resting  on  his  thighs,  the  anterior  urethra  from  the  bulb 
forward  is  gently  massagetl  after  suitable  cleansing  of  the  foreskin  and 
meatus. 

4.  A  12  Fr.  soft-rubber  catheter  is  gently  j)asse(l  into  the  urethra  to 
the  bulb  and  then  eonneeted  with  a  150  c.c.  Janet-Frank  syringe  filled 
with  warm,  normal  salt  solution.  The  bend  of  the  catheter  beyond  the 
meatus  drooj^s  into  a  sterile  glass  resting  in  the  basin  so  that  the 
irrigation  of  the  lU'ethra  is  readily  carried  into  the  glass. 

5.  While  the  left  hand  sui)])orts  the  jjcnis  and  catheter  from  change 
in  their  relation  to  each  other  and  to  the  glass,  the  right  hand  irrigates 
the  anterior  urethra  with  the  entire  contents  of  the  syringe,  150  c.c. 

This  step  secures  Glass  I  or  the  anterior  urethral  glass. 

6.  The  urethra  is  again  gently  massaged,  from  the  bulb  forward,  in 
order  to  dislodge  clinging  discharge  not  brought  away  by  the  first 
massage  and  the  irrigation.  The  irrigation  is  repeated  exactly  as 
before. 

This  step  ])roduces  Glass  II  or  the  control  anterior  urethral  glass. 

7.  The  patient  now  passes  about  one  inch  of  urine  into  a  glass,  or 
more  if  be  has  had  his  bladder  as  full  as  directed  in  the  preliminary 
instructions.  The  contents  of  the  posterior  urethra  are  in  this  way 
carried  into  the  specimen  along  an  anterior  canal  previously  cleared  by 
the  two  irrigations  just  described. 

This  stei^  presents  (ilass  III  or  the  posterior  urethral  glass. 

8.  Having  thus  cleansed  the  urethra  as  a  whole,  the  character  of  the 
urine  in  the  bladder  must  be  known  and  is  secured  by  passing  a  small 
rubber  catheter  into  the  bladder  and  drawing  off  a  part  or  the  whole 
of  the  contents. 

This  step  collects  Glass  IV  or  the  bladder  glass. 

9.  The  diagnosis  is  completed  by  knowing  the  condition  of  the 
secretion  of  the  prostate  and  seminal  vesicles.  If  the  patient  still  has 
considerable  urine  in  his  bladder  massage  of  these  organs  is  done  at 
once,  or  with  the  catheter  still  in  place  the  bladder  is  filled  with  warm 
normal  salt  solution  and  then  the  catheter  is  withdrawn  and  the 
massage  performed. 

This  step  shows  Glass  V  or  the  massage  glass. 
The  author's  seven-glass  test^  consists  in  adding  the  following  details 
to  those  stated. 

10.  After  the  bladder  glass  is  secured,  the  prostate  is  very  carefully 
massaged  with  special  reference  to  not  touching  either  seminal  vesicle 
or  their  ducts  as  they  pass  through  the  middle  of  the  prostate.  This 
may  be  done  with  reasonal)le  and  satisfactory  success  by  the  experi- 
enced finger. 

This  step  presents  Glass  A'  or  the  prostatic  glass. 

11.  The  bladder  is  again  filled  up  to  the  limit  of  comfort  with  normal 
salt  solution  whose  quantity  is  noted  to,  say,  200  c.c,  and  the  right 

'  New  York  Medical  Journal,  May  10,  1916. 


LA  BORA  TOR.  Y  EX  A  MINA  TION 


455 


seminal  vesicle  is  tlioroiif^lily  7ri,'iss,'i,f^(;(],  cfirefiilly  uvoiflirif^  th(!  prostate, 
and  then  the  patient  evacuates  lialf  his  l^ladder  contents  flOO  c.cj. 

This  step  contains  Glass  VI  or  the  right  seminal  vesicular  glass. 

12.  The  left  seminal  vesicle  is  now  massaged  as  its  fellow  was  and 
its  products  Hushed  out  with  what  remains  in  the  bladder,  or  if  the 
patient  has  not  divided  th(!  contents  of  the;  l)hi(ld(;r  well,  more  fluid  must 
first  be  run  into  the  bladder  or  this  vesicle  left  until  the  next  visit  for 
examination. 

This  step  secures  Glass  VII  or  the  left  seminal  vesicular  glass. 

The  limitations  and  cautions  of  these  two  tests  noted  in  the  intro- 
ductory paragraph  must  always  be  borne  in  mind.  It  is  well  to  mas- 
sage the  less  diseased  seminal  vesicle  first  so  that  contamination  of  the 
contents  of  the  posterior  urethra  will  be  limited. 


TABLES  OF    AUTIIOR'S   SEVEN-GLASS  TEST   FINDINGS. 
Posterior  Chronic  Urethritis  with  Prostatitis. 


I. 


II. 


III. 


IV. 


V. 


VI. 


VII. 


Contents    of 
glasses. 


Clear 

few  shreds 
(turbid) 


Clear 


Turbid    or 
large 
shreds  or 
prostatic 
elements. 


Clear 


Turbid, 
abundant 
prostatic, 
detritus. 


Clear. 


Clear. 


Posterior  Chronic  Urethritis  with  Unilateral  Seminal  Vesiculitis. 


Contents    of 
glasses. 


Clear  or 
few  shreds 
(turbid). 


Clear. 


Turbid    or 
large 
shreds; - 
vesicular 
elements. 


Clear. 


Clear    (few 
elements 
from  pros- 
tate   and 
vesicle). 


Clear 

(slightly 
turbid) . 


Turbid; 
many 
vesicular 
shreds. 


Posterior  Chronic  Urethritis  with  Bilateral  Seminal  Vesiculitis. 


Contents    of 


Clear 
few  shreds 
(turbid) 


Clear. 


Turbid; 
large 
shreds; 
vesicular 
elements. 


Clear. 


Clear  (tur- 
bid). 


Tiirbid; 
many 
vesicular 
shreds. 


Turbid; 
many 
vesicular 
shreds. 


Chronic  Urethritis  with  Prostatitis  and  Unilateral  Seminal  Vesiculitis. 


Contents    of 

Clear       or 

Clear. 

Turbid    or 

Clear. 

Turbid; 

Clear 

Abundant 

glasses. 

few  shreds 

large 

abundant 

(slightly 

seminal 

(turbid). 

shreds. 

prostatic 
elements 
(seminal 
vesicular 
elements) . 

turbid) . 

vesicular 
elements. 

Posterior  Chronic  Urethritis  with  Prostatitis  and  Bilateral  Seminal  Vesiculitis. 


Contents    of 

Clear       or 

Clear. 

Turbid    or 

Clear. 

Turbid; 

Turbid; 

Turbid; 

glasses. ' 

few  shreds 

large 

abundant 

seminal 

seminal 

(turbid). 

shreds 

prostatic 

vesicular 

vesicular 

(prostatic 

elements 

elements. 

elements. 

and  vesi- 

(seminal 

cular  ele- 

vesicular 

ments)  . 

detritus) . 

Posterior  Chronic  Urethritis  with  Cystitis. 


Contents    of 
glasses. 


Clear 
few  shreds 
(turbid). 


Clear. 


Turbid    or 
large 
shreds: 


Turbid; 
abundant 
bladder 
elements. 


Clear. 


Clear. 


Clear. 


456  GEXERAL  PRIXCIPLES  OF  DIAGNOSIS 

Kollmann'tt  trst^  is  also  a  five-glass  test  but  does  not  respect  the 
contents  of  the  bhukler  and  is  therefore  defective  in  this  most  impor- 
tant detail.  Tlie  anterior  urethra  is  irrigated  twice,  with  the  patient 
standing,  respectively  for  Glass  1  and  Glass  II  and  then  the  patient 
e\acuates  his  bladder  into  three  glasses.  These  steps  are  assumed  to 
distinguish  conditions  within  the  anterior  and  posterior  portions  of  the 
canal. 

Young's  test-  consists  of  seven  glasses  of  which  the  anterior  urethral 
and  control  glasses  are  seciu'cd  by  a  double  irrigation  for  each  such  glass. 
Of  these,  the  second  washings  are  done  with  a  glass  irrigator  passed  to 
the  bulb  of  the  urethra  and  directing  its  current  outward.  The  patient 
then  e\acuates  into  three  glasses  which  are  taken  to  represent  the 
contents  of  the  posterior  urethra.  The  bladder,  however,  is  not  cathe- 
tcrizcd  so  that  the  uncertainty  of  the  method  duplicates  that  of  the 
Kollmann  test. 

Multiple  Glass  Tests  with  Irrigation  and  with  Dye. — General  Plan. — 
These  tests  include  washing  the  anterior  urethra  free  of  its  accumu- 
lated discharge  after  staining  it  with  a  dye.  Two  only  are  recognized, 
Kromeyer's  and  Lohnstein's,  and  even  these  are  not  in  frecpient  use  on 
account  of  technical  difficulties,  overrefinement,  uncertain  deductions 
and  doubtful  value. 

Kromeyer's  Test.^ — The  anterior  urethra  is  stained  by  the  injection  of 
4  or  5  c.c.  of  0.1  per  cent,  of  watery  solution  of  methylene  blue,  retained 
for  se^•eral  minutes  for  penetration.  The  patient  next  evacuates  his 
urine  and  all  stained  products  are  assumed  to  belong  to  the  anterior 
urethra.  The  fallacy  is,  however,  that  the  dye  may  pass  by  capillary 
attraction  between  the  two  surfaces  of  the  posterior  urethra  as  they 
lie  more  or  less  in  contact  and  thus  stain  its  contents  also.  Moreover, 
the  bladder  contents  are  not  investigated. 

Lohnsteins  Test.^ — This  procedure  is  much  like  the  foregoing  in  being  ' 
a  five-glass  irrigating  method  with  a  dye.  The  steps  are  first  free 
irrigation  of  the  anterior  urethra  into  Glasses  I  and  I.I  with  0.5  per 
cent,  watery  solution  of  potassium  ferrocyanide  until  the  outflow  is 
clear.  The  next  step  is  to  wash  the  urethra  free  of  the  potassium  ferro- 
cyanide solution  which  is  determined  by  the  addition  of  chloride  of  iron 
as  the  Prussian-blue  test  of  these  washings.  When  this  chemical  is 
entirely  out  of  the  canal  the  last  step  is  evacuation  of  the  bladder  by 
the  patient  into  three  glasses  and  the  addition  of  more  chloride  of 
iron.  Filaments  which  do  not  show  the  Prussian  blue  are  assumed  to 
come  from  the  posterior  urethra.  The  fallacies  underlying  this  test 
are  its  undue  delicacy,  the  likelihood  that  the  dye  may  reach  the  pos- 
terior urethra  or  fail  to  enter  glands  of  the  anterior  urethra,  which 
later  give  up  unstained  plugs  and  finally  the  absence  of  proper  test  of 
the  bladder  contents. 

'Oberlander  u.  Kollmann:    Die  chron.  Gononhce,  1910,  p.  49. 

'  Johns  Hopkins  Hospital  Reports,  1904,  xiv. 

'  Quoted  by  Luys,  loc.  cit. 

*  Deutdch.  med.  Wochenschrift,  1893,  xix,  p.  1072. 


URINALYSIS  457 

Laboratory  Examination  of  Filaments. — Diagnosis  of  the  nature  of 
filaments  includes  the  featin-es  of  preparation  of  s}jeei]nen,  microscopic 
features  and  bacteriological  examination.  The  preparation  of  the 
specimen  for  the  laboratory  consists  by  the  platinum  loop  method  in 
snaring  a  number  of  filaments,  esi)ecially  some  which  float  and  some 
which  sink,  with  a  flamed  platinum  needle  upon  a  clean -and  sterile 
microscopic  slide,  teasing  them  out  as  much  as  possible,  absorbing 
excess  moistm-e  with  filter  paper  and  fixing  with  equal  parts  of  alcohol 
and  ether  ready  for  the  stain.  By  the  pipette  method  it  consists  in 
sucking  shreds,  especially  mucous  types,  into  a  pipette  with  as  little 
urine  as  possible  and  in  the  same  way  spreading  them  upon  the  slide. 
Accompanied  by  suitable  label  and  brief  report  of  clinical  facts  and 
diagnosis  the  specimens  are  ready  for  the  laboratory  expert.  The 
microscopic  features  include  bacteria  whose  nature  must  be  proved 
and  many  of  the  following  elements :  (a)  mucus  in  nearly  pure  state 
or  mixed  with  cells  and  detritus  exactly  as  pus  is,  (b)  fibrin  rare  alone 
but  mixed  with  other  elements  and  (c)  pus  including  the  other  two 
elements  and  adding  red  blood  cells,  detritus,  epithelium  from  the 
urethra  and  from  the  ducts  and  acini  of  glands  and  finally,  (d)  sperma- 
tozoa dead  and  entangled  in  the  pus  especially  in  cases  of  involvement 
of  the  seminal  vesicles  and  occasionally  of  the  prostate.  The  culture 
of  filaments  is  done  exactly  in  one  for  both  of  the  two  methods  stated  for 
slide  preparations,  with  the  one  change  that  the  shred  secured  is  spread 
upon  the  surface  of  a  slant  culture  adapted  for  the  gonococcus,  which  as 
already  explained  always  requires  special  media  and  careful  protection 
from  chilling  in  order  to*have  it  grow  at  all  or  well.  It  is  advisable  to 
take  at  least  three  tubes,  of  which  one  remains  in  the  office  of  the  urolo- 
gist as  the  control  tube,  and  the  other  two  are  sent  to  the  pathologist 
as  the  laboratory  tubes.  It  is  necessary  to  select  shreds  which  float  and 
shreds  which  sink  for  the  full  examination,  so  that  the  author  frequently 
prefers  two  sets  of  tubes,  one  lot  containing  cultures  of  the  floating 
filaments  and  the  other  set  showing  cultures  of  the  sinking  threads. 
In  this  cultural  work  frequent  transplantation  is  required  for  a  final 
diagnosis — a  detail  which  rests  with  the  laboratory  expert. 

URINALYSIS. 

Definition. — For  the  purpose  of  diagnosis  of  gonococcal  urethritis 
urinalysis  is  of  little  importance  with  respect  to  its  usual  physical  and 
,  chemical  characters,  but  of  much  more  value  with  respect  to  micro- 
scopic and  bacteriological  features.  The  organisms  sought  are  the 
gonococcus  and  its  various  associates  which  in  a  few  obsciu-e  cases  come 
away  in  the  urine  after  having  defied  other  methods  of  secm"ing  speci- 
mens, such  as  have  already  been  elucidated.  These  methods  might  be 
called  the  clinical  examination  of  the  urine.  Such  investigations  are 
represented  by  the  laboratory  specimens  described  for  the  seven-glass 
test  of  the  author  and  the  expressed  contents  of  the  glands  of  Co^^■per, 
the  prostate  gland  and  the  seminal  vesicles,  which  may  be  found  in  the 


45S  GEXERAL  PRIXCIPLES  OF  DIAGXOSIS 

urine  as  well  as  in  dilatinti-  fluid  artilieially  introduced  into  the  bladder 
— in  either  ease  after  snitahle  clinical  manipulation  of  the  respective 
origans.  » 

Physical  and  Chemical  Characters. — Physical  Characters. — Color 
and  odor  and  speciiit-  ^-raxitx'  are  of  no  \'alue  in  u'onococcal  diagnostics. 
Transparency  and  translucency  show  or  sui^iivst  the  i)resence  of  blood, 
pus,  nuicus,  fat  antl  chyle.  The  meaning  of  clear  urine  in  which  shreds 
are  found  has  already  been  made  clear  under  the  subject  of  nuiltiple 
glass  tests  on  jiage  45'). 

Chemical  Characters  as  to  Normal  Elements. — Reaction  is  not  of  great 
help  and  the  same  may  be  said  as  to  urea,  uric  acid,  chlorids,  phos- 
phates, phosphoric  acid,  total  solids  antl  other  connnon  substances 
searched  for  in  the  recognition  of  renal  insufficiency  or  disease. 

Chemical  Characters  as  to  Abnormal  Elements  is  of  greater  \ahie  as  the 
pus  and  blood  in  the  urine  of  se\ere  gonococcal  disease  are  corroborative 
of  the  fact  of  infection.  Albumin  must  be  traced  as  to  its  source  in 
virtue  of  the  importance  of  the  p^airia  which  ma}'  be  its  sole  cause  and 
of  albmnin  itself  as  a  sign  of  urinary  disorder.  The  sources  may  be 
renal,  vesical,  ])rostatic,  ^•esicular  and  urethral,  and  are  suggested  or 
pro\ed  respectively  by  such  other  corroborative  signs  as  casts  and 
renal  epithelia  in  kidney  involvement,  mucus  and  squamous  vesical 
epithelia  in  bladder  disease,  prostatic  elements  and  epithelia  in  inva- 
sion of  the  prostate,  spermatozoa  and  special  epithelia  in  vesicular 
complications  and  finally  familiar  urethral  cells  in  ordinary  urethral 
infection.  Sugar  is  independent  of  gonococcal  infection  except  as  a  rare 
and  peculiar  element  in  those  intense  infectiolis  with  systemic  compli- 
cations and  severe  bodily  depreciation.  In  such  cases  it  becomes  an 
index  of  the  severity  rather  than  the  character  of  the  disease.  Bile 
elements,  as  pigment,  acid  and  salts,  are  of  no  value.  IIemoglol)inuria, 
consisting  of  the  coloring  matter  of  the  blood  in  solution  in  the  urine 
in  contrast  with  red  cells  in  suspension,  is  practically  never  seen  except 
in  wasting  malnutrition,  such  as  scurvy  and  in  intense  prolonged  in- 
fections, such  as  scarlet  fever  and  malaria.  It  is,  therefore,  of  no 
reference  to  gonococcal  invasion.  Lipuria  may  confuse  the  diagnosis 
in  cases  complaining  of  prolonged  turbidity  of  the  urine  without  relief, 
through  the  fact  that  this  cloudiness  simulates  pus.  Sedimentation  of 
the  lu-ine  rapidly  clears  up  this  matter,  as  the  globules  of  fat  rise  as  few, 
many  or  even  a  distinct  layer  to  the  top  of  the  specimen  glass.  Lipuria 
may  be  temporary  accompaniment  of  the  ingestion  of  fatty  or  oily 
foods  or  medicines  and  is  often  seen  in  rather  minute  c^uantities  after 
the  passing  of  instrimients  lubricated  with  oils  or  after  the  instillation 
of  oil  into  the  ureters  in  the  removal  of  calculi  without  ojjeration,  or 
after  the  api)lication  of  oil  to  the  cavity  of  the  bladder.  The  cause  of 
such  presence  is  at  once  obvious,  as  the  globules  are  usually  very  large 
and  not  microscopic,  as  in  true  lipuria.  Chyluria  presents  fatty  sub- 
stances in  emulsion  as  distinguished  from  suspension  in  lijmria,  exactly 
as  seen  in  the  chyle  of  final  digestive  stages  and  of  the  lymi)hstream. 
Microscopic  determination  is  final  and  its  source  is  not  gonococcal, 


URINALYSIS  459 

but  such  systemic  disease  as  filariasis  and  accidental  introduction  into 
the  bloodstream  from  the  injury  of  marrow  bones  and  of  the  lymph- 
stream  or  nodes  or  from  absorption  in  extensive  abscess  processes. 
Like  lipuria  it  should  be  borne  in  mind  in  patients  prcscntiiijf  themselves 
with  the  history  of  unexplained  persistent  turl)i(lity  of  the  urine. 

Microscopic  Characters.  —  Definition.  —  iVl icros('opic  examination 
of  the  urine  consists,  by  dehnition,  in  the  diagnosis  of  the  sediment  and 
the  bacteriology  of  the  urine.  Specimens  are  secured  by  sedimentation 
or  centrifugation. 

Sedimentation  consists  in  allowing  the  urine  to  stand  until  abnormal 
constituents  gravitate  to  the  bottom  of  the  container,  by  preference 
with  a  conical  base  for  concentration  of  the  elements  and  with  suitable 
protection  against  contamination  from  outside  sources.  The  delay 
incident  to  sedimentation  is  recognized  as  a  great  disadvantage,  because 
it  permits  chemical  decomposition  to  be  begun  in  specimens  without  it 
or  to  be  increased  and  continued  in  urines  with  it  and  because  through 
these  changes  it  leads  to  physical  disintegration  or  change  in  such 
factors  as  red  and  white  blood  cells,  pus,  epithelia,  casts,  cylindroids 
and  the  Hke  and  because  bacteria  already  in  the  urine  and  inactive  or 
added  to  it  while  standing  begin  to  grow  and  change  the  fluid  totally 
from  the  condition  in  which  it  was  passed.  Centrifugation  involves 
placing  the  urine  in  the  receiving  tube  of  a  centrifuge  and  submitting 
it  to  rapid  revolutions  for  a  brief  period  of  time,  shortest  w^th  high- 
speed electrical  apparatus  and  in  ascending  order  longer  in  h}'draulic 
and  hand  machines. 

Manifestly  the  high,  uniform,  brief  or  prolonged  speed  of  the  electric 
machine  renders  it  without  superior  for  this  and  all  similar  service. 
After  from  three  to  five  minutes'  centrifuging  the  smallest  possible 
specimen  is  sucked  from  the  bottom  of  the  m-ine  tube  into  a  pipette, 
spread  widely  and  thinly  upon  a  slide,  freed  of  excess  urine  with  blotting 
paper  and  covered  with  a  cover-glass.  A  first-class  microscope  is 
essential,  adjusted  for  the  examination  with  the  low-power  lens  for 
the  majority  of  the  elements  or  w^ith  the  midpower  lens  for  closer 
study  of  doubtful  points.  High-power  lenses  are  reserved  for  bacterio- 
logical work. 

Elements  for  Study. — In  the  sediment  are  found  red  and  white  blood 
cells,  pus,  epithelia,  casts  and  crystals,  which  vary  somewhat  in  accord- 
ance with  the  chemical  reaction.  Acid  urine  is  redundant  in  uric  acid, 
urates,  oxalates,  hippuric  acid  and  rarely  leucin,  tjTosin  and  cystin, 
while  alkaline  urine  shows  triple  phosphates,  calcimn  phosphate,  basic 
magnesium  phosphate,  ammonium  m*ate  and  calcium  carbonate.  These 
crystals  are  of  no  importance  in  gonococcal  studies,  except  that  their 
presence  in  large  quantities  may  readily  irritate  the  mucosa  and  pro- 
long the  disease  and  would  in  such  circumstances  require  dietetic  and 
medicinal  relief.  The  general  and  special  significance  of  the  other 
elements  may  be  stated  as  follows: 

Red  blood  corpuscles  may  find  their  source  at  any  point  of  the  genital 
and  urinary  tracts  and  become  important  when  sufficiently  numerous 


460  GEXERAL  PRIXCIPLES  OF  DFAGXOSIS 

to  be  a  definite  factor  in  eitlier  microscopic  or  macroscopic  exami- 
nation. Intense  gonococcal  in\asi()n  in  acnte  disease  and  irritable 
granulations  in  or  about  stricture  and  similar  lesions  in  clu'onic  infec- 
tion may  be  the  soiu-ce  of  blood  cells  or  bleeding.  Fresh  specimens  of 
urine  show  them  in  the  form  of  their  passage,  which  may  be  normal  or 
altered  according  to  the  site  and  character  of  the  lesion  with  or  without 
retention  of  the  extravasated  blood.  In  the  normal  form  they  present 
on  the  flat  a  biconcave  disk,  without  nucleus,  yellowish  singly,  slightly 
reddish  in  groups  or  rolls  and  on  edge  they  a])pear  of  dumb-bell  form. 
Older  specimens  are  variously  crumpled  and  crcnated.  As  to  signi- 
ficance they  occur  as  a  few  cells  in  normal  urine  and  more  mnncrously 
up  to  the  limit  of  free  hemorrhage  in  various  diseases.  When  a  mani- 
festly important  factor  their  source  must  be  determined  without  fail, 
as  discussed  by  the  author.^ 

Pus  cells  also  ma>'  ha\'e  their  origin  in  any  area  of  the  urogenital 
apparatus  and  likewise  become  significant  when  in  sufficient  quantity 
to  be  a  positive  factor  in  either  microscopic  or  macroscopic  study. 
Gonococcal  infection  is  always  accompanied  by  pus  cells  which  are  so 
numerous  in  acute  disease  as  to  make  the  urine  opaque  or  so  few  in 
chronic  tlisease  as  to  occur  only  in  the  shreds.  On  the  other  hand,  pus 
is  the  direct  result  or  a  by-product  in  so  many  lesions  of  the  sexual  and 
urinary  apparatus  in  both  sexes  that  only  a  bacteriological  study  will 
reveal  the  gonococcus,  its  allies  or  other  invading  organism.  Fresh 
specimens  of  urine  alone  portray  these  cells  in  their  shape  on  passage, 
which  may  be  of  their  ordinary  normal  forms  or  altered  in  chronic 
disease  and  retention.  Old  specimens  of  urine  artificially  change  the 
appearance  of  pus  cells,  especially  during  the  decomposition  of  alkaline 
urine.  Such  changes  in  both  the  m-ine  and  the  pus  may  occur  within 
the  body  and  in  either  circmiistance  consist  in  more  or  less  coalescence 
into  various  irregular  masses  after  they  have  previously  puffed  up  and 
burst.    Nuclei  are  thereafter  invisible. 

The  source  of  pus  cells  is  chiefly  by  diapedesis  of  white  blood  cells 
and  exfoliation  of  epithelial  cells  as  parts  of  destructive  processes  in  any 
part  of  the  \'arious  organs  of  the  s}'stem.  Regular  associates  of  pus  cells 
are  epithelia,  casts,  mucus  and  bacteria,  among  the  last  for  our  purpose 
the  most  important  are  the  gonococcus,  the  Bacillus  coli  and  other 
pyogenic  organisms.  Distinction  between  epithelial  and  pus  cells  is 
ready  by  adding  Gram's  iodin  solution  to  the  smear  which  stains  the 
pus  cells  a  faint  yellow  and  the  epithelial  cells  a  deeper  yellow  in  the 
body  and  almost  a  brown  in  the  nucleus,  or  by  adding  dilute  acetic 
acid  which  clears  the  field  and  brings  out  the  polynuclei.  In  form  pus 
cells  are  on  the  flat  more  or  less  circular  or  irregular  and  on  edge  mere 
disks  or  spheres.  They  are  mononuclear  or  polynuclear  with  granular 
bodies  both  visible  in  the  fresh  state  but  absent  tlirough  coagulation 
in  older  specimens.  As  to  significance,  a  scattered  few  pus  cells  are 
normal  in  every  urine  but  may  increase  from  this  state  to  a  number  so 

'  Pedersen,  V.  C:  New  York  Med.  Jour.,  May  3,  1913. 


PLATE    II 


FIG.  S 


FIG.   S 


Varieties  of  Epithelium.     (Ultzmann.) 

Figs.  1,  2,  8  and  4.     Epithelium  from  the  bladder,  the  renal  pelvis  and  the  ureter. 
Fig.  5.     Red  blood  eorpiiseles. 


URINALYSIS  461 

great  as  to  render  the  urine  opaque.  Wlx^nevcr  the  normal  quantity 
is  exceeded  the  source  of  the  pus  must  be  known,  as  discussed  by  the 
author. '^  Advanced  processes  show  the  pus  cells  in  c^sts  and  clumps 
usually  from  the  upper  urinary  organs,  while  scattered  cells  may  come 
from  any  point  whatever. 

Scattered  epithelial  cells;  numerous  pus  cells  singly  and  gathered 
into  masses. 

Epithelia. — Fresh  specimens  are  again  to  be  preferred  although 
decomposition  alters  epithelia  less  than  most  of  the  other  constituents 
in  the  urine.  As  to  source,  these  cells  may  come  from  any  part  from  the 
deepest  excretory  elements  of  the  kidney  to  the  external  limits  of  the 
urinary  canal  and  sexual  organs,  from  which  especially  in  the  female 
many  cells  are  washed  away  during  micturition.  This  fact  renders  the 
catheterization  of  both  sexes  in  many  circumstances  the  sole  means  of 
securing  a  specimen  assuredly  from  the  bladder  only.  Epithelia  may 
also  come  from  any  layer,  of  which  there  are  commonly  three:  super- 
ficial, middle  and  deep.  As  a  rule,  the  superficial  cells  show  the  type 
predominating  while  the  middle  and  deeper  layers  are  the  transitional 
forms.  In  the  urogenital  tract  the  epithelial  cells  are  often  similar  in 
form,  such  as  the  cuboidal  or  round  cells  from  the  posterior  urethra, 
ureters  and  pelves  which  vary  slightly  in  size,  granular  appearance  of 
the  cell  bodies  and  size  of  the  nuclei.  In  form,  the  common  varieties 
are  flat  or  squamous,  cuboidal  or  round,  cylindrical  or  caudate  or 
spindle,  and  finally  ciliated.  In  general  distribution  through  the  lower 
urinary  tract  the  flat  pavement  cell  prevails  and  is  largest  in  the 
vagina  and  vulva  and  smaller  in  the  male  urethra  throughout  the  fossa 
navicularis  and  neck  of  the  bladder  and  a  mean  in  the  bladder  itself. 
Cuboidal  or  round  cells  appear  at  many  points  of  the  sexual  and  urinary 
organs,  especially  in  the  deeper  layers,  w^here  they  occur  in  the  lu-inary 
organs  in  the  urethra,  bladder,  ureters  and  pelves  and  some  portions 
of  the  tubules  of  the  kidneys,  and  in  the  sexual  organs  in  the  prostate 
and  vagina.  Round  cells  in  the  strict  sense  are  probably  cuboidal  cells 
altered  after  having  left  their  sites.  Cylindrical  or  caudate  or  spindle 
cells  have  the  same  distribution  as  the  foregoing  and  are,  as  a  rule,  from 
the  deeper  layers  as  the  first  stage  of  development.  They  are,  there- 
fore, found  in  the  urethra,  bladder,  ureter  and  kidneys  along  the  urinary 
passages  and  in  the  prostate  and  seminal  vesicles  in  the  sexual  glands. 
Some  authorities  state  that  cilia  are  on  the  cells  of  the  seminal  vesicles. 
The  minute  distinctions  with  the  microscope  may  so  easily  err  that  the 
source  of  epithelia  must  be  judged  chiefly  from  other  signs  in  the  iu"me 
rather  than  from  mere  size  and  form.  In  significance,  epithelia  vary 
as  to  their  soiu-ce  and  condition  and  the  latter  in  accordance  with  the 
decomposition  of  the  urine  within  or  without  the  body  and  the  bacteria 
present.  A  few  "words  are  essential  concerning  the  various  kinds  of 
epithelia  from  the  meatus  to  the  kidneys  in  the  main  portions  of  the 
tract:  m'ethra,  bladder,  m'eters  and  kidneys. 

1  Pedersen,  V.  C. :    New  York  Med.  Jour.,  December  13,  1913. 


462  GEXEIiAL  I'RIXCIPLES  OF  Dl .U.WOi^IS 

In  the  distinction  of  ironoc-ort-al  infection,  es])ecinlly  of  chronic  form, 
knowledge  of  tlie  epitheiia  distributed  along  the  urethra  and  within  the 
glands  and  associated  organs  is  of  value  in  indicating  the  source  of 
obscure  lesions.  And  when  a  seven-glass  test  of  the  author  has  shown 
that  the  pus  conies  from  the  bladder  or  kidneys  the  character  of  the 
epitheiia  is  again  of  great  importance. 

rriihnil  F.pifliclid. — The  form  of  the  cells  changi-s  with  the  portion 
of  the  canal.  At  the  meatus  and  within  the  fossa  na\icularis  and  again 
at  the  neck  of  the  bladder;  in  other  words,  at  the  outlet  and  inlet  of  the 
canal,  the  cells  are  of  fiat  or  jjavement  form.  From  the  fossa  navicularis 
to  the  membranous  urethra  the  type  changes  to  moderately  columnar 
or  cuboidal  form,  which  continues  with  cluinge  in  size  along  the  pros- 
tatic urethra  until  transition  into  the  flat  cells  of  the  neck  and  cavity 
of  the  bladder  occurs.  In  the  glands  of  the  mucosa  and  the  prostate, 
such  as  the  glands  of  Littre,  the  crypts  and  the  acini  and  ducts  of  the 
prostate  cuboidal  or  columnar  cells  arc  present.  In  the  seminal  \-esicles 
and  their  ducts  caudate  or  spindle  cells  appear  and  some  authorities 
say  cilia.  Instrumentation  and  applications  within  the  canal  are 
invariably  followed  by  much  increase  in  the  number  of  cells  cast  oft' 
in  the  m-ine  for  a  da>'  or  two. 

]'csical  Epitheiia. — In  the  bladder  the  ])avement  cell  predominates 
over  the  entire  surface  and  the  other  forms  only  in  the  deeper  layers  as 
transitional  stages,  so  that  the  cuboidal  cells  are  in  the  second  layer 
and  the  caudate  in  the  deeper  layer.  In  health  there  are  always  a  few 
pa\ement  cells  from  the  bladder  cast  off  with  urine,  which  changes  in 
superficial  inflammation  to  a  large  number  in  single  cells  and  large 
patches  and  in  deeper  inflammation  cuboidal  and  caudate  cells  are 
frequently  seen.  Common  associates  of  such  disease  are  large  quanti- 
ties of  mucus,  ])us,  blood  and  bacteria.  It  is  probable  that  the  round 
cells  are  cuboidal  types  swollen  out  of  shape  in  the  urine.  As  in  the 
urethra,  irrigation  of  the  bladder  excepting  with  perfectly  bland  fluids, 
such  as  sterilized  water,  normal  salt  solution  and  boric  acid  water, 
causes  temporary  free  desquamation  of  the  lining.  Unless  this  fact 
is  remem]>ered,  the  i)resence  of  these  numerous  cells  in  a  urinalysis 
might  lead  to  erroneous  deduction. 

Ureteral  Epitheiia. — The  form  of  these  cells  from  the  superficial 
la\er  is  cuboidal  or  round,  according  to  the  age  of  the  specimen,  and 
from  the  dee]X'r  lasers  spindle  and  caudate.  The  general  a])pearanee 
as  to  size  and  granules  of  body  and  nucleus  is  a  close  resemblance  to 
the  epitheiia  of  the  prostatic  urethra  and  prostate,  from  which  they  are 
distinguished  by  the  absence  of  other  prostatic  elements  and  by  the 
presence  of  casts  and  other  signs  of  renal  lesion,  because  when  the 
ureters  are  involved  sufficiently  to  make  their  epitheiia  of  imi)ortance 
the  kidneys  are  also  profoundly  diseased. 

Renal  Epitheiia.— Vreteral  cells  and  pelvic  cells  are  about  identical, 
which  is  to  be  expected  because  the  pelvis  of  the  kidney  is  really  the 
origin  of  and  the  collecting  pouch  for  the  ureter  and  should,  therefore, 
have  the  same  lining.    The  cells  from  the  kidney  are  various.    In  the 


URINALYSIS  463 

pelvis,  they  are  cuboid  or  round  and  caudate  and  thus  resernlilin^,  as 
stated,  the  cells  found  within  the  inernbranous  anfl  [prostatic  urethra 
except  as  to  size  and  other  elements  accompanying  them  in  the  urine. 
In  the  convoluted  tubules,  they  are  likewise  cuboidal  or  round,  much 
like  the  pelvic  cells,  but  have  small  markedly  pfranuiar  bodies  and  rela- 
tively large  and  distinctly  marked  nuclei.  In  the  straight  tubules,  the; 
epithelia  is  columnar  and  cuboidal.  As  to  significance,  it  may  be  said 
that  in  health  there  are  always  a  few  epithelia  from  the  kidneys  as  from 
other  portions  of  the  urinary  canal,  in  the  ordinary  process  of  cellular 
death  ever;\"where  in  the  body.  When  the  number  becomes  pathologic, 
there  are  always  found  also  pus,  blood  and  casts.  To  the  casts  the 
epithelia  may  be  attached  in  scattered  :e\h  or  so  densely  as  to  form 
the  so-called  epithelial  casts,  fully  described  under  this  subject. 

Diagnosis  of  epithelia  is  arrived  at  by  mensuration,  study  of  the  cells 
singly  and  in  groups  and  recognition  of  the  importance  of  associated 
elements  in  the  specimen.  Chetwood^  aptly  sums  up  the  mensuration 
as  follows:  "The  pus  cell  serves  as  a  standard  of  measurement  for  the 
comparative  sizes  of  the  different  epithelial  cells.  Generally  speaking, 
the  large  pavement  epithelium  of  the  bladder  is  about  six  or  seven  pus- 
cell  diameters  in  width  (vaginal  epithelium  is  somewhat  larger).  The 
same  type  of  cell  from  the  urethra  is  about  five  pus-cell  diameters  in 
width  and  the  urethral  columnar  cells  are  about  four  pus-cell  diameters 
in  their  widest  portion.  The  cuboidal  cells  of  the  bladder  are  nearly 
as  large  as  the  more  superficial  flat  cells.  The  round  epithelia  from  the 
prostate  are  the  same  size  as  those  from  the  ureter,  and  smaller  than 
those  of  the  pelvis  of  the  kidney,  or  about  two  pus-cell  diameters. 
Those  from  the  kidney  tubules  are  much  smaller,  being  one  and  one- 
third  the  diameter  of  a  pus-^ell.  The  round  cells  from  the  kidney  pelvis 
are  about  three  pus-cell  diameters.  The  caudate  or  pear-shaped  cell 
from  the  pelvis  are  about  the  diameter  of  a  pus  cell  in  width  and  about 
four  diameters  in  length.  The  same  t^^^e  of  cell  from  the  deeper  layers 
of  the  bladder  is  much  larger." 

As  to  study  of  the  cells,  it  is  to  be  noted  that  in  general  the  cuboidal 
or  round,  columnar  or  caudate  or  spindle  cells  with  small  very  granular 
bodies  and  relatively  very  large  costly  granular  nuclei  are  from  the 
kidney;  but  this  deduction  is  not  conclusive  unless  there  are  corrobo- 
rative elements  in  the  specimen. 

As  to  the  associated  factors,  one  may  state  that  diagnosis  usually 
depends  most  on  them  in  corroboration.  They  are  albumm.  pus  cells, 
red  blood  cells,  casts,  cylindroids  and  mucus  in  plugs  and  strings. 
From  the  urethra  shreds  are  of  great  importance.  Finally,  epithelia 
alone  are  without  significance  unless  in  large  quantities,  as  all  forms 
appear  in  health. 

Casts. — Definition. — During  renal  disease  not  only  do  such  substances 
appear  in  the  urine  as  will  not  in  health  filter  through  the  kidneys,  but 
some  of  them  coagulate  in  the  tubules  to  form  molds  of  the  canals, 

1  The  Practice  of  Urology,  1913,  pp.  65  and  66, 


464  GENERAL  PRIXCIPLES  OF  DIAGXOSIS 

which  are  technically  known  as  casts.  As  to  significance,  casts  are 
known  to  be  the  signs  of  medical  anil  surgical  lesions  of  one  or  both 
kidneys,  and  are  so  connnon  in  bilateral  medical  renal  affections  that 
tliey  have  been  most  widely  studied  in  this  connection  and  have 
subconsciously  come,  therefore,  to  be  regarded  as  accompaniments 
chiefly  of  such  conditions,  more  or  less  indirectly  to  the  exclusion  of 
surgical  invohenients  of  these  organs.  This  is  a  serious  error,  Ixx-ause 
all  surgical  renal  disease  is  more  or  less  directly  accompanied  by  inllam- 
mation  with  or  without  infection,  which  carries  with  it  immediately 
the  sfime  signs  as  are  seen  in  medical  developments  and  summed  up  in 
alterations  of  i)hysical  and  chemical  characters  and  presence  of  albumin, 
casts,  pus,  blood,  ej)ithelia,  crystals,  detritus,  changed  urea,  excretion, 
changed  dye-test  signs  and  the  like  in  the  urine.  Inasmuch  as  many  of 
these  signs  may  apj^ear  from  any  point  of  the  urinary  tract,  casts 
become  a  very  imjiortant  corroborative  or  suggestive  sign  of  the  renal 
source  of  these  abnormal  elements  and  therefore  assume  as  much 
weight  in  surgery  as  in  medicine. 

In  the  recognition  of  gonococcal  urethritis  casts  are  of  value  in  show- 
ing the  actual  source  of  pus  in  those  patients  who  have  it  in  the  urinary 
organs  above  the  outlet  of  the  bladder,  as  distinguished  from  the  sexual 
organs  and  as  indicated  by  the  seven-glass  test  of  the  author.  Their 
presence  will  at  once  show  whether  the  kidneys  are  in^•olved  in  the 
process  independently  of  the  bladder  or  combined  wdth  it.  In  strictly 
urethral  conditions,  therefore,  casts  must  be  considered  as  valid  indi- 
cators of  the  origin  of  pus,  along  with  their  usual  associates. 

Varieties. — ^'arieties  in  their  ascending  order  of  clinical  interi)retation 
as  a  basis,  are:  (1)  hyaline,  (2)  granular,  finely  or  coarsely,  (3)  epithelial 
and  (4)  waxy  casts.  Special  forms,  as  determined  by  the  addition  to 
the  hyaline  basis  of  each  of  the  elements  suggested  by  the  names 
api)lied  to  the  casts  are:  (1)  pus,  (2)  blood,  (3)  fatty,  (4)  crystals  and 
detritus  and  (5)  bacteria.  Organisms  in  their  nature  cannot  make  up 
a  whole  cast  but  are  sometimes  seen  in  pus  and  epithelial  specunens. 
In  their  form,  casts  are  cylindrical,  wuth  more  or  less  uniform  or  broken 
borders,  with  rather  straight,  sinuous,  tortuous  or  almost  spiral  bodies, 
with  both  ends  rounded  or  one  end  ragged,  with  length  to  extend  half- 
way across  the  field  or  so  short  as  to  be  very  numerous  in  one  field  and 
with  density  so  slight  as  to  require  much  decreased  illumination  for 
visibility  of  hyaline  casts  or  so  great  as  to  permit  study  only  by  reflected 
light  in  many  pus  and  blood  casts.  All  grades  of  density  between  these 
limits  are  seen. 

Hyaline  Casts  (Gelatin  or  Vitreous  Casts). — These  are  the  earliest 
in  occurrence  and  the  commonest  in  health  and,  therefore,  the  least 
clinically  important  casts  when  seen  alone.  In  size  hyaline  casts  are 
the  largest,  so  that  one  may  extend  far  across  the  field,  and  in  diameter 
are  very  small  or  large  according  to  the  tubule  from  which  they  come. 
In  outline  their  borders  may  be  fairly  straight  and  uniform  or  sinuous 
and  twisted,  also  according  to  their  tubules  of  coagulation.  Both  ends 
of  hyaline  casts  are  usually  rounded,  on  bodies  which  may  be  of  glassy 


PLATE  111 


FJG.   1 


FIG.  3 


Urinary  Analysis.     (Ultznnann.) 

Fig.    1.     Epithelial  easts  seen   in   aevxte  desquamative  nephritis. 

Figs.  2  and  4,.     Hyaline  easts  from  renal  congestion  and  ehronie  nephritis. 

Fig.  8.    Coarse  granular  easts  from  aeute  nephritis,  -with  some  blood  eorpuseles. 


URINALYSIS  465 

clearness  or  very  finely  granular  or  delicately  striated.  They  are  the 
most  difficult  of  all  casts  to  see  in  the  field  and  always  require  greatly 
subdued  light.  As  to  significance,  a  few  hyaline  casts  are  always  seen 
in  health,  dependent  on  slight  dietetic  error,  active  or  violent  exercise 
and  factors  adding  to  blood-pressure  in  the  young  and  in  later  years 
they  are  a  common  element  in  the  urine  without  renal  lesion.  The 
absence  or  presence  of  albumin  and  other  kidney  elements  is  the  divid- 
ing line  between  such  as  are  without  or  with  danger  signs.  In  profound 
disease  one  therefore  sees  along  with  them  any  or  all  other  kinds  of 
casts,  epithelia,  albumin  and  sometimes  pus  and  blood  according  to 
circumstances.  Large  numbers  of  hyaline  casts  in  apparent  health 
may,  therefore,  suggest  the  wisdom  of  minute  search  for  their  cause 
and  of  observation  of  the  patient  at  short  intervals,  every  few  weeks, 
for  other  signs  of  kidney  breakdown,  because  many  such  casts  are  often 
forerunners  of  serious  signs. 

Granular  Casts. — Granular  casts  may  be  fine  or  coarse,  according  to 
the  characters  of  the  granules  seen  within  the  bodies  of  the  casts.  In 
nature  they  are  probably  hyaline  casts  whose  masses  have  been  changed 
by  coagulation  of  the  albuminous  material,  more  densely  at  certain 
points  rather  than  uniformly  or  by  precipitation  of  unknown  matter 
in  finely  subdivided  state.  A  few  of  these  granular  casts  seem  to  show 
small  fat  globules  and  have  the  remnants  of  epithelia  attached  to  or 
imbedded  within  them,  of  which  the  nuclei  alone  remain.  As  to  sig- 
nificance, granular  casts  represent  the  next  development  of  nephritis 
and  are  very  numerous  indeed  in  all  varieties,  sizes  and  forms  in  marked 
cases  and  may  be  said  to  appear  in  health  in  scattered  specimens. 

In  size  and  diameter  they  are  usually  smaller  than  hyaline  casts, 
possibly  because  they  are  somewhat  more  apt  to  come  from  the  upper 
tubules. 

Epithelial  Casts.- — Epithelial  casts  may  be,  first,  hyaline  casts  to  whose 
surface  a  few  epithelia  have  been  glued  or  so  many  as  to  make  a  com- 
plete cover,  or,  second,  true  epithelial  plugs  either  more  or  less  solid 
or  having  an  irregular  lumen.  In  size  epithelial  casts  are  among  the 
smallest,  as  a  rule,  as  they  come  from  the  finer  tubules  and  their  sur- 
fa  les  and  outlines  are  essentially  irregular  and  ends  broken.  Along  with 
them  the  urine  always  shows  scattered  epithelia,  many  other  forms 
of  cast  and  other  signs  of  kidney  involvement.  The  desquamation 
present  invariably  means  severe  inflammation  and  blood  cells  and 
even  blood  casts  may  be  associates.  Epithelial  casts  are  not  seen  in 
health. 

Waxy  Casts. — ^Waxy  casts  are  shown  in  Plate  IV,  Fig.  4,  and  are  also 
called  amyloid  casts,  through  their  origin  in  amyloid  degeneration  of  the 
kidney.  In  form  they  are  usually  of  irregular  or  uncommonly  regular 
outline,  with  ends  broken  and  ragged,  with  color  a  peculiar  whitish- 
yellow  waxiness  or  a  glassy  brightness.  They  are  without  transparency 
and  with  moderate  translucency,  but  with  high  refraction  of  light. 
Their  density  is  commonly  not  uniform.  As  to  significance,  waxj'"  casts 
are  highest  in  the  scale  of  importance  and  represent  advance  lesions, 
30 


466  GENERAL  PRINCIPLES  OF  DIAGNOSIS 

Pus  Casts. —  Pus  oasts  consist  of  formed  masses  of  pus  cells,  and 
have  much  the  same  significance  and  associates  as  pus  in  large 
quantities  in  the  urine,  as  fully  discussed  under  this  subject. 

Blood  Casts.- — Blood  casts  ha\e  already  been  alhuled  to  as  develop- 
ments and  associates  of  ejMthelial  casts  and  are  made  of  massed  blood 
cells.  They  are  very  commonly  accompanied  by  large  numbers  of 
scattered  blood  cells  and  nearly  every  other  possible  element  of  renal 
disease. 

Fatty  Casts. — Fatty  casts  are  more  commonly  those  in  which  fat 
globules  after  error  in  diet,  injury  of  the  marrow  of  bones  and  the 
mhibition  of  fatty  medicines  become  attached  to  commoner  varieties 
of  cast. 

Bacterial  Casts.— Bacterial  casts  are  not  connnon  because  bacteria 
in  their  nature  could  hardly  be  sufficiently  numerous  of  themselves  to 
form  true  plugs  of  the  tubules.  But  they  may  be  so  numerous  in  the 
medium  and  so  freely  within  epithelial  and  pus  casts  on  staining  as  to 
warrant  this  term. 

Crystalline  Casts.- — Crystalline  casts  are  less  common  than  other  kinds, 
and  consist  of  crystalline  or  amorphous  plugs  of  the  various  urinary 
salts.  In  infancy  before  the  kidneys  become  accustomed  to  their  new 
surroundings  such  casts  of  uric  acid  and  urates  are  not  rare. 

False  Casts. — False  casts  are  mucous  developments  rather  as  strings 
than  as  true  plugs  or  molds  and  originate  either  in  kidney  or  ureter 
by  unhealthy  secretion  rather  than  by  coagulation  of  mucus.  In  form 
they  bear  a  rude  resemblance  to  large  casts,  with  shaggy,  stringy 
outlines  and  ends  without  tapering  or  rounding.  The  bodies  show  all 
the  characters  of  mucus  but  may  be  slightly  granular  and  may  or  may 
not  clear  on  the  addition  of  dilute  acetic  acid.  Cylindroids  is  another 
name  applied  to  them  and  they  maj^  appear  alone  and  without  signifi- 
cance in  health  but  in  disease  mvariably  have  any  and  all  of  the  fore- 
going associates. 

Crystalline  and  Amorphous  Deposit. — Significance.^ — In  health 
all  urine  shows  a  certain  amount  of  crystalline  deposit  after  centri- 
fugation,  which  depends  much  on  diet  and  temporary  conditions  of 
metabolism,  but  in  disease  it  represents  permanent  defect  of  meta- 
bolism so  that  the  urine  becomes  saturated  with  one  or  the  other  or 
several  salts.  These  precipitate  within  the  body  at  any  point  of  the 
urinary  system,  chiefly  as  the  result  of  infection  of  the  urinary  passages 
with  secondary  decomposition  of  the  urine  in  the  kidney,  its  pelvis, 
ureter  or  bladder  or  are  very  rapidly  cast  down  during  the  slightest 
decomposition  on  standing.  This  fact  shows  the  importance  of  fresh 
specimens  in  the  determination  of  the  meaning  of  these  crystals. 
Decomposition  and  ammoniacal  fermentation  of  normal  urine  on 
standing  in  a  specimen  glass  will  result  in  almost  all  the  crystals  seen 
in  alkaline  urine,  so  that  acid  urines  should  be  examined  at  once  to 
anticipate  such  misleading  change  and  alkaline  urines  should  not  be 
allowed  to  stand  because  of  misleading  increase  of  their  constituents 
as  passed. 


FIG.   1 


PLATE    IV 


FIG.  S 


FIG.  4 


Urinary  Analysis.       (Ultznnann.) 

Figs.  1  and  2.  Hyaline  easts.  In  Fig.  2  they  are  covered  with  crystals  of  urate 
of  ammonium. 

Figs.  S  and  4.  Fine  granular  and.  waxy  easts.  Fig.  3  is  from  a  case  of 
advanced    chronic     Bright's    disease.       Fig.   4  is    from    a    ease    of    amyloid     disease. 


PLATE    V 


FIG.    1 


FIG.   2 


FIG.  8 


FIG.  4. 


o'-^J       '^V^-C^         ^ 


Urinary  'Analysis.     (Ultzmann.) 

Figs.   1  and.  2.     Crystals  of  oxalate  of  lime. 

Fig.   S.     Crystals  of  eystin. 

Fig.   4.     Crystals  of  letAcin  and  tyrosin. 


URINALYSIS  407 

In  gonococcal  conditions  in  which  a  multiple  glass  test  has  shown  the 
pus  to  coinc  from  the  upjXT  urinary  organs  the  presence  of  crystals 
and  am()r])]ious  deposit  will  serve  only  to  ilhistratc;  j)rocesses  which 
may  there  be  the  source  oF  the  ])us.  If  suj)i)l<;ni(;iited  l)y  bacteriology 
and  a  study  of  other  elements  present,  a  distinction  is  always  possible. 

Varieties. — As  previously  stated,  crystals  vary  with  the  reaction  of 
the  urine  so  that  acid  urines  in  health  show  a  few  and  in  disease  many 
crystals  of  uric  acid,  urates,  and  oxalates,  as  the  most  important  sedi- 
ment and  as  the  rare  and  less  significant  crystals  hippuric  acid,  Icucin, 
tyrosin  and  cystin.  Alkaline  urine  does  not  occur  in  health  and  shows 
the  following  decomposition  products,  a  few  of  which  may  be  seen  in 
neutral  urine  of  health  or  normal  urine  rendered  temporarily  alkaline 
by  the  administration  of  suitable  medicines.  These  crystals  are 
triple  phosphates,  calcium  phosphate,  basic  magnesium  phosphate, 
ammonium  urate  and  calcium  carbonate.  Of  these  the  last  is  of  least 
importance. 

Uric  Acid  Crystals. — Uric  acid  crystals  occur  in  acid  urine,  usually  as 
a  reddish  deposit  to  the  naked  eye  if  abundant  and  are  caujed  by  over- 
indulgence in  nitrogenous  food  or  by  nitrogenous  waste  as  in  violent 
exercise  or  prolonged  labor.  Their  size  makes  them  among  the  largest 
urinary  crystals.  Their  form  is  polymorphous  and  variously  poly- 
hedral, stellate  and  rhomboid,  as  shown  in  the  foregoing  plate.  Various 
form-groupings  render  them  beautiful  crystals  having  in  the  field  a 
yellow  or  yellowish-red  or  colorless  aspect  and  to  the  naked  eye  a  red- 
dish hue.  They  are  soluble  in  alkali  and  heat  and  as  to  significance  are 
recognized  as  common  in  health  in  small  numbers  but  in  large  quantities 
as  suggesting  the  uric  acid  diathesis,  faulty  metabolism  or  renal  stone. 
The  latter  detail  must  be  corroborated  by  other  signs  of  stone,  described 
in  the  sections  dealing  with  lithiasis  of  kidneys,  ureters  and  bladder, 
in  Chapters  XIV,  XV  and  XVI. 

Amorphous  Urates  (Brick  Dust  Deposit)  have  the  same  occurrence, 
cause  and  significance  as  uric  acid  and  the  form  of  small  dustlike 
granules  of  j^ellow  to  red  color  in  the  field  and  of  definite  red  color  to 
the  naked  eye  in  the  specimen  glass.  The  addition  of  alkali  or  the 
application  of  heat  to  the  specimen  dissolves  them.  Plate  VI  portrays 
their  general  appearance  under  the  microscope. 

Calcium  Oxalate  Crystals  occur  in  scattered  crystals  in  acid  urine 
under  whose  products  it  should  be  classed,  but  as  they  are  soluble  in 
the  addition  of  acid  they  may  not  precipitate  until  the  urine  becomes 
neutral  or  faintly  alkaline  in  the  very  early  decomposition  stages. 
Alkalies  do  not  dissolve  them  so  that  they  persist  in  ammoniacal 
urine  (Pellew).^  Their  cause  seems  to  be  fruit  and  vegetable  diet 
abundant  in  oxalic  acid,  such  as  strawberries,  asparagus,  rhubarb  and 
tomatoes,  also  nervous  instability,  faulty  nutrition  and  indifterent 
general  health.  Their  size  is  smaller  than  uric  acid  although  they  are 
large  and  small.    Their  form  is  twofold,  most  commonly  octahedral, 

1  Manual  of  Practical  Medical  and  Physiological  Chemistry,  1893,  p.  271. 


468  GENERAL  PRIXCIPLES  OF  DIAGNOSIS 

of  long  or  short  planes,  and  loss  oomnionly  honr-glass  or  (Unnb-bell. 
resembling  a  very  large  blood  cell  on  edi::c.  The  color  is  white,  bright, 
reflecting  and  refracting  light  and  their  solubility  is  in  acid  and  not 
alkaline  media.  Their  significance  is  in  health  recent  and  abundant 
\egetable  or  fruit  diet  or  in  disease  faulty  digestion  and  assimilation  or 
oxalate  diathesis  with  lithiasis,  wliich  nuist  be  sustained  by  other  signs, 
such  as  nuicus,  blood,  pus  and  large  mnnbers  of  these  crystals.  In  the 
treatment  of  gonococcal  disease,  of  which  part  is  always  a  neutraliza- 
tion of  the  urine,  these  crystals  must  be  looked  for  and  if  possible 
eliminated,  otherwise  their  sharp  corners  and  edges  may  readily  irritate 
the  mucosa  and  ])rolong  tlic  syni]itoms. 

Ammoniomagnesium  Phoaphate  (Triple  Phosphate)  Crystals  occur  in 
alkaline  urine,  caused  by  chemical  change  set  up  by  infection,  inflam- 
mation and  ulceration  at  any  point  of  the  kidneys,  ureters  or  bladder 
and  \ery  conuuonly  in  decomposing  urine  of  prostatic  obstruction. 
In  size  these  crystals  are  rather  large,  about  equal  to  those  of  uric  acid 
and  in  form  polyhedral,  forming  the  so-called  "coffin-lid"  crystals  as 
the  commonest  type  and  the  leaf  crystals  as  the  uncommon  variety. 
The  color  is  a  brilliant  wjiite  reflecting  and  refracting  light.  They 
dissolve  on  the  addition  of  acid  to  the  urine.  Their  significance  is  in 
fresh  specimens,  decomposition  of  the  urine  and  almost  always  the 
infection  and  suppuration  which  accompany  it.  In  very  large  numbers 
verified  by  all  other  means  of  research  they  suggest  lithiasis  and  are 
very  common  in  cystitis  and  pyelitis.  In  older  specimens  they  prove 
decomposition  of  the  urine  before  the  examination. 

Amorphous  Calcium  Phosphate  is  commonly  known  as  amorphous 
phosphate  and  occurs  in  alkaline  or  neutral  urine  almost  invariably 
associated  with  triple  phosphate.  The  cause  is  the  same  as  that  of  the 
latter  crystals,  but  they  are  much  more  commonly  the  ])roduct  of 
conditions  of  nervous  ill  health  and  malnutrition,  so  that  some  patients 
will  void  a  urine  so  rich  in  them  as  to  simulate  thin  semifluid  mortar. 
The  size  and  form,  indicated  by  the  term  amnrphoiis,  are  that  of  faintly 
visible  dust,  which  dissolves  on  the  addition  of  acid  and  heating  of  the 
urine.  As  to  significance  they  show  a  vegetable,  fish  or  sea  food  diet, 
the  ingestion  of  alkaline  waters  and  drugs,  defective  assimilation, 
nervous  disturbance  and,  like  triple  phosphate,  infection  and  decom- 
position of  the  urine  within  the  body  or  specimen  container.  In  gono- 
coccal affections  the  use  of  alkalies  to  neutralize  the  urine  and  the 
mental  um'cst  of  the  patient  often  ])roduce  large  ([uantities  of  amor- 
phous calcimn  i)hosphate  which  is  difficult  to  distinguish  from  pus, 
especially  in  the  later  periods  of  the  disease,  when  free  pus  in  the 
urethra  is  insufficient  to  render  the  urine  turbid.  It  is  well  therefore  to 
add  acid  to  the  urine  at  frequent  intervals  in  order  to  remove  these 
phosphates,  leaving  the  ])us  behind  for  study. 

Ammonium  Urate  Crystals  occur  in  alkaline  urine  and  are  always 
caused  by  decomj)osition  as  a  disease  process  within  the  organs  or  as  an 
artifact  within  the  laboratory.  Their  size  is  small  and  their  form 
either  smooth  globules  or  spined  globules,  both  singly  or  in  pairs  or 


PLATE    Vi 


FIO    2 


FIG.   S 


^^  ^*   %      / 

Urinary  Analysis.     (Ultzniann.) 

Figs.  1,  2,  8  and  -4.     Different  fornis  of   crystals  of  urie  aeicl. 

Fig.   S.     Crystals  of  urate  of  annxLoniun^i. 

Fig.    6.     Crystals  of  urate  of  amnionium    and    triple    phosphate  crystals. 


PLATE    VII 


FIG.  8 


Urinary  Analysis.      (Ultzmann.) 

Figs.  1  and  2.     Crystals  of  the  triple  phosphates.       Fig.   1  is  the  eommon  form. 
Fig.   8.     Crystals  of  phosphate  of  linie. 
Fig.   4.     Crystals  of  urate  of  sodiui-n. 
Fig.   S.      Amorphous  urate  of  sodium. 


PLATE    VI J 1 


FIG.  3 


FIG.  4. 


Urinary  Analysis.     (Ultzmann.) 

Figs.  1  and  2.    Sedirtient  of  ehronie  cystitis.     Fig.    2.     Moderate  bleeding. 
Figs.  8  and  4..     Spermatozoa  and  the  yeast  fungus. 


URINALYSIS  4G9 

triplets  of  reddish-brown  or  yellow  hue  as  shown  in  Plate  VI.  ^J'he 
prickle  specimens  are  sometimes  called  "hedgehog"  or  "chestnut- 
burr"  crystals.  The  application  of  heat  and  acids  to  the  urine  results 
in  their  solution.  Their  significance  lies  in  the  fact  that  they  regularly 
accompany  the  other  phosphates  as  the  products  of  infection,  decom- 
position and  suppuration  and  if  like  them  they  are  very  numerous 
search  for  lithiasis  by  the  other  means  of  diagnosis  should  always  be 
undertaken. 

Bacteriology. — Flora  of  the  Urethra  in  health  comprises  a  number  of 
organisms  which  are  harmless  to  the  individual  but  which  soon  decom- 
pose the  urine  outside  the  body.  The  most  important  are  the  micro- 
coccus urese  and  the  bacterium  urese.  These  may  become  pathogenic 
in  their  character  by  leading  to  decomposition  of  urine  within  the  body 
and  thus  induce  or  promote  cystitis,  especially  of  ammoniacal  type. 
In  infectious  disease  it  is  known  that  the  specific  bacteria  may  pass 
through  the  kidneys  and  urinary  passages  at  first  without  lesions  and 
later  often  with  lesions,  particularly  nephritis,  cystitis  and  sometimes 
urethritis.  A  catheterized  specimen  is,  therefore,  essential  in  order  to 
eliminate  as  far  as  possible  organisms  which  may  be  present  in  the 
urethra  alone  and  not  infrequently  irrigation  of  the  canal  is  required  in 
cases  where  there  is  little  doubt  of  important  urethral  organisms. 
The  gonococcus  is  the  most  frequent  microbe  within  the  m*ethra  whose 
presence  must  be  determined  as  not  within  the  bladder  and  the  upper 
m'inary  organs.  The  methods  employed  have  already  been  shown 
under  the  general .  heading  of  ^Multiple  Glass  Tests  on  page  450. 

The  organs  in  the  urine  are  therefore  either  nonpathogenic  or 
pathogenic. 

Nonpathogenic  Organisms.-^Nonpathogenic  organisms  may  be  defined 
as  those  which  do  not  cause  disease  of  the  urinary  organs  themselves 
dm"ing  their  passage  through  them  or  excite  changes  within  the  lU'ine 
while  in  the  body.  The  double  role  of  the  micrococcus  and  bacterium 
m'ese  and  of  the  organisms  of  infectious  disease  has  already  been  dis- 
cussed as  in  this  sense  both  nonpathogenic  and  pathogenic  with  reference 
to  the  urinary  system. 

Pathogenic  Organisms. — Pathogenic  organisms  comprise  a  very  long 
list  because  most  infectious  diseases  have  a  period  of  nephritis  during 
which. the  majority  of  the  exciting  microbes  are  present  in  the  urine 
associated  with  all  the  other  signs  of  acute  renal  inflammation,  such  as 
red  blood  cells,  white  blood  cells,  pus,  epithelia,  casts  and  crystalline 
and  amorphous  deposit.  The  commonest  organisms  and  the  diseases 
in  which  they  are  found  comprise:  (1)  the  gonococcus  in  gonococcal 
m-ethritis  in  the  free  pus  of  acute  and  in  the  skreds  of  chronic  lesions, 
(2)  the  pnemnococcus  in  mfection  of  the  lungs  and  various  compli- 
cations of  pneumonia,  (3)  Staphylococcus  pyogenes  albus  and  aureus 
and  (4)  Streptococcus  pyogenes  in  septic  processes  and  the  streptococcus 
in  erysipelas  associated  with  the  (5)  Streptococcus  erysipelatus,  (6) 
Bacillus  coli  communis  in  intestinal  inflammation,  appendicitis,  gall- 
bladder infection  and  from  unknown  causes,  (7)  Bacillus  pyocyaneus 


470  GEXERAL  PRfXCIPLES  OF  DIAGXOSfS 

in  sei)tie  i:)rocesses  with  blue  ])us,  (S)  Bacillus  tyi^hosus  in  typhoid  and 
paratyphoid  eases  in  nearly  50  per  cent,  of  the  total  imtients,  (9) 
Haeillus  anthraeis  in  anthrax,  (10)  Bacillns  mallei  in  iilanders  and  (11) 
Bacilhis  tnberenlosis  in  many  forms  of  snrii'ieal  and  occasionally  in 
medieal  tnberenlosis. 

This  partial  list  illustrates  the  importance  in  gonococcal  or  suspected 
gonococcal  infections  of  securing  specimens  proi)erly  and  of  having 
them  thoroughly-  searched  for  the  source  of  i)us  in  obscure  cases.  Of 
the  organisms  stated,  the  most  im])ortant,  because  more  connnon,  are 
the  Bacillus  tuberculosis,  Bacillus  coli  communis  and  the  pyogenic 
staphylococci  and  streptococci  and  the  less  important,  because  more 
rare,  are  the  Bacillus  pyocyaneus,  Bacillus  typhosus,  Bacillus  anthraeis 
and  Bacillus  mallei. 

Parasites.— Parasites,  other  than  the  fission-fimgi  or  bacteria,  may 
also  infest  the  urine  and  are  likewise  either  nonpathogenic  or 
pathogenic. 

Noupathodciiic  l\tr(isifc.s'. — These  are  usually  the  moulds  and  yeast. 
The  latter  is  present  in  all  normal  urine  and  very  abundant  in  diabetic 
urine,  and  plays  an  important  part  in  its  cystitis  and  is  the  essential 
of  the  fermentation  test  for  sugar.  Infusoria  belong  in  this  group  of 
parasites  occur  usually  in  old  alkaline  specimens  and  are  said  to  com- 
prise chiefly  the  amoeba^  and  the  Trichomonas  vaginalis  (von  Jaksch^). 

Pathogenic  Parasites. — Pathogenic  parasites  include  chiefly  the 
worms  and  their  eggs  and  are  illustrated  by  Distoma  hematobium  and 
Filaria  sanguinis  hominis,  both  characterized  chiefly  by  tropical  origin 
and  hematuria,  and  echinococcus,  revealed  by  booklets,  eggs  or  mem- 
brane and  frequent  in  some  countries  but  imcommon  in  the  United 
States.  It  seems  to  arise  from  the  rupture  of  cysts  from  points  outside 
the  urinary  organs  and  canals  into  them  and  is  then  associated  with 
corresponding  symptoms.  If  occurring  within  the  kidneys  or  bladder 
hematuria  and  ])yuria  are  in^•ariable  accompaniments  along  with  the 
booklets,  membrane  and  sometimes  eggs.  x\scarides  are  not  seen  in 
the  urine  unless  there  is  a  fistula  into  the  bowel  from  the  bladder  or 
urethra. 

In  dealing  with  obscure  or  suspected  gonoccocal  lesions  parasites  must 
be  borne  in  mind  in  the  same  way  as  the  bacteria,  as  just  stated,  and 
their  possible  presence  warrants  a  careful  analysis  in  all  such,  cases. 

Special  Bacteria,  as  they  occur  in  the  urine,  are  for  our  purposes 
in  the  order  of  their  occurrence  the  gonococcus.  Bacillus  coli  com- 
munis, Streptococcus  pyogenes.  Staphylococcus  pyogenes,  and  Bacillus 
tuberculosis. 

Gonococcus. — Gonococcus  occurs  very  frequently  although  less  fre- 
quently than  the  Bacillus  coli  communis,  and  has  its  source  in  acute 
or  chronic  urethritis  or  its  more  important  comi)lications,  such  as 
prostatitis,  vesiculitis  and  funiculitis.  It  may  be  washed  into  a  speci- 
men glass  from  the  urethra  by  the  lu'inary  stream  or  be  found  in  the 

»  Tr.  by  Cagney,  4th  ed.,  1897,  p.  271. 


URJNALYSfS  471 

bladder  })y  direct  transit  in  continuity  or  by  incidental  infection 
through  irrigation  and  instrumentation.  (jonoco(;cal  cystitis  is  apt 
to  be  most  severe  in  the  trigonum  as  a  trigonitis  from  which  it  rarely 
extends  to  the  bladder  as  a  whole  until  and  unless  other  pyogenic  or- 
ganisms are  associated  with  it,  particularly  the  Bacillus  coli  communis. 
Trigonitis  in  women  is  very  common  and  more  readily  studied  than  in 
men.  The  gonococcus  may  be  found  in  the  kidney,  its  pelvis  and  ureter 
rarely  as  an  ascending  infection  from  a  cystitis  and  more  commonly 
as  a  hematogenous  development  from  penetration  of  the  organisms  into 
the  bloodstream,  from  chronic  foci  in  the  seminal  vesicles  and  the 
prostate.  In  such  cases  arthritis  is  not  uncommonly  present  and  the 
organism  is  almost  invariably  associated  with  other  pyogenic  organisms, 
although  occasionally  pure  cultures  of  the  gonococcus  are  found  in 
these  manifestations. 

Bacillus  Coli  Communis  is  the  most  common  organism  in  the  urine 
of  the  group  mentioned  and  has  its  origin  in  the  large  variety  within 
the  lower  intestine  known  as  the  colon  group.  It  is  a  normal  inhabitant 
and  benefactor  within  the  large  bowel  in  health  but  may  in  disease 
become  the  source  of  vicious  purulent  processes  of  hematogenous 
origin,  exemplified  particularly  by  appendicitis,  cholecystitis,  pyelo- 
nephritis and  cystitis.  It  is  probable  that  the  colon  bacillus  normally 
passes  through  the  urinary  organs  without  exciting  lesions.  Bassler^ 
found  it  present  in  9  per  cent,  of  191  fresh  urines  from  patients  without 
urogenital  symptoms.  It  undoubtedly  reaches  its  own  foci  of  disease 
in  the  urinary  organ  from  the  bloodstream  or  the  lymphstream  or  both 
and  is  almost  always  associated  with  other  important  organisms, 
especially  the  Bacillus  tuberculosis,  Staphylococcus  pyogenes.  Strepto- 
coccus pyogenes,  Streptococcus  ipyocyaneus  and  the  gonococcus.  It 
is  the  originator  of  acute  and  chronic  alkaline  cystitis  even  in  the 
absence  of  the  other  organisms  just  stated,  such  as  the  Bacillus  tuber- 
culosis and  the  pyogenic  group.  Tuberculosis  may  invade  the  urinary 
organs  usually  with  early  bleeding  and  without  much  pus  being  present 
until  the  colon  bacillus  is  added  to  the  process,  when  the  purulence 
immediately  becomes  active  and  excessive,  at  any  and  all  points  of  the 
system — kidneys,  ureters  or  bladder — by  profound  compromise  of  the 
local  resistance  and  with  the  result  of  nephritis,  pyelonephritis,  ureter- 
itis and  cystitis.  Increased  hematuria  by  the  Bacillus  tuberculosis  is 
usually  the  next  step  in  these  cases.  As  a  common  ally  of  the  gono- 
coccus it  becomes  of  importance  to  the  student  of  gonococcal  infections. 
Turbidity  of  the  urine  is  often  caused  by  numberless  colon  bacilli  which 
may  filter  through  the  kidneys,  in  the  opinion  of  many,  without  caus- 
ing disease,  but  this  fact  is  not  accepted  universally. 

Pyogenic  Organisms. — Streptococci  and  Stapliylococci .• — The  pus- 
forming  cocci  are  second  in  frequency  in  the  urine  only  after  the  colon 
bacillus,  if  the  gonococcus  is  not  included.  Their  som"ces  are  usually 
lesions  of  the  mucous  membranes  for  the  streptococcus  and  lesions  of 

1  Med.  Rec,  July  6,  1912. 


472  GENERAL  PRINCIPLES  OF  DIAGNOSIS 

the  skin  for  the  staphylococcus.  Their  entrance  into  the  urine  is 
much  Hke  that  of  the  gonococcus  from  the  urethra  by  being  washed 
away  in  the  urinary  stream  and  from  the  l)hulder  by  direct  inocu- 
lation througli  the  traumatism  of  instruments  and  other  means 
and  by  lowered  local  and  general  resistance,  as  seen  in  anemia  and 
tuberculosis  and  generally  unhygienic  conditions.  Henuitogenous 
entrance  of  these  germs  into  the  urinary  system  is  an  undoubted  fact, 
as  the  expression  of  numy  sc})tic  ])rocesses  and  as  establishment  of 
septic  infarct  and  other  abscess  of  the  kidneys.  Any  point  wliatcAcr  of 
the  canal  may  be  invaded  from  the  meatus  upward — urethra,  bladder, 
ureters  and  kidneys.  In  the  urethra  they  are  local  in  their  manifes- 
tations and  likewise  in  the  bladder  as  nongonococcal  urethritis  and 
cystitis,  although  in  the  latter  the  inflammation  is  apt  to  be  universal 
in  distinction  from  the  trigonitis  of  gonococcal  invasion.  In  the  com- 
plications of  gonococcal  disease,  especially  when  abscesses  are  present 
in  the  prostate,  seminal  vesicles  and  testicles  the  streptococcus  and 
staphylococcus  are  ai)t  to  be  present.  In  the  kidney  the  entrance  of 
the  germ  is  usiudly  hematogenous  from  a  focus  elsewhere  within  or 
without  the  urogenital  tract  and  less  commonly  the  entrance  is  by 
direct  ascent  froni  the  bladder  along  the  ureter.  The  character  of  the 
infection  is  always  se^•ere,  no  matter  what  part  of  the  urogenital  tract 
is  attacked  and  these  organisms  are  often  associated  with  others  as 
well  as  with  each  other.  It  is  rather  well  established  and  widely 
accepted  that  rheumatism  occurring  during  gonococcal  manifesta- 
tions is  rarely  if  ever  due  to  the  gonococcus  alone,  but  most  commonly 
to  the  streptococcus  associated  with  it.  Recovery  of  these  organisms 
from  the  urine  rests  on  the  examinations  of  urethral  smears  and  on 
sedimentation  and  centrifugation  of  the  urine  under  strict  antiseptic 
precautions  and  finally  by  culture.  Animal  inoculation  is  of  value  in 
determining  the  virulence. 

Bacillus  Tulerculosis. — Bacillus  tuberculosis  is  in  occurrence  less 
frequent  than  many  of  the  others  but  in  importance  of  equal  rank.  Its 
source  is  practically  always  hematogenous  and  lymphogenous,  or  both 
and  hardly  ever  by  direct  inoculation.  As  in  the  respiratory  system, 
so  in  the  urogenital  system,  any  organ  or  any  part  thereof  may  be 
involved  in  almost  any  degree  of  lesion;  thus  are  invaded,  as  exam- 
ples, the  kidneys,  their  pelves,  ureters,  bladder,  prostate,  testicles, 
and  seminal  vesicles — any  and  all,  as  primary  and  secondary  foci. 
In  primary  lesions  of  the  prostate,  testicles  and  seminal  vesicles 
the  bacilli  enter  the  urine  by  direct  discharge  of  these  glands 
into  the  urethra,  whereas  in  the  urinary  organs  the  bacilli  probably 
pass  through  the  kidneys  with  the  urine.  In  the  bladder  tubercles 
may  break  down,  ulcerate  and  thus  discharge  their  bacilli.  In  the 
kidney  any  part  of  the  organ  may  be  involved — the  parenchyma 
and  pelvis  or  both  in  few  or  many,  small  or  large,  slowly  or  rapidly 
destructive  lesions.  As  long  as  the  excretory  function  at  the  focus  is 
maintained  bacilli  are  thrown  into  the  urine,  but  often  when  the  walling 
off  process  is  complete  or  when  excretion  has  been  destroyed,  the  bacilli 


PLATE    IX 


Bacillus  Coli  Comniunis. 


T^' 


"  „   «i- 


V  =  ^ 


55," 


Gonococcus. 


f        » 


I  ^-      ^^'      W.  A'      .  . '*;^       .'*-» 
;    M  /;^  .'••  •'■4.  ^- ■       *  . 


(/ 


7 


J\. 


Streptococcus    Pyogenes. 


Bacillus  Tuberculosis. 


:£' 


'■^-■^      '■^■■^ 


Pneumoeoceus. 


Staphylococcus. 


Magnified   lOOO  diameters 

Organisms   Commonly  Found  in  Chronic  Urethritis  with  the  Exception 
of  the  Bacillus  Tuberculosis,  ^A^hich  is  Rare.     (Dudley. i) 


^Principles  and  Practice  of  GynecoJogj-,  6th  Ed.,   1913 


U  RIM  A  LYSIS  473 

are  absent  or  very  scanty,  even  when  the  disease;  has  involv(;(]  niueli 
of  the  kidney.  Tlie  detection  of  the  13af;inus  tnhcrcuKjsis  in  the  virine 
depends  on  careful  collection  of  one  or  many  twenty-four-hour  speci- 
mens, under  antiseptic  precautions,  in  a  conical  jar  whose  sediment 
is  then  carefully  removerl,  centrifuged  and  examined  with  the  micro- 
scope. Animal  inoculation  is  the  chief  means  of  establishing  the 
identity  of  the  germ  found,  although  various  differential  stains  and 
the  trained  eye  are  usually  successful  through  morphology  alone.  The 
Bacillus  tuberculosis  except  in  staining  qualities  and  cultural  character- 
istics and  animal  infection  is  closely  resembled  by  the  smegma  bacillus 
of  the  prepuce  of  both  men  and  women.  Further  refinements  in  this 
question  belong  to  a  work  on  bacteriology. 

Gonococci  in  the  Urine. — As  a  means  of  verifying  other  tests  and  of 
making  the  diagnosis  when  it  is  difficult  in  some  individuals,  especially 
women,  to  obtain  specimens,  importance  is  attached  to  analysis  of  the 
urine  for  the  gonococcus.  It  sometimes  permits  the  diagnosis  of 
obscure  infection  in  the  prostate  and  seminal  vesicle  after  free  discharge 
has  stopped  and  the  patient  seems  to  be  well.  Its  limitations  reside 
in  the  characteristics  of  the  urine  and  the  gonococcus. 

In  the  first  place  the  urine  rapidly  decomposes  and  thereby  makes 
this  diagnosis  diflficult  or  impossible.  A  fresh  specimen  of  urine  is 
essential.  The  first  urine  passed  in  the  morning  is  the  best  because 
the  exudate  containing  pus  and  organisms  collects  during  the  night 
and  washes  out  from  the  urethra  with  the  first  evacuation.  Stripping 
the  canal  as  far  as  possible  from  end  to  end  before  the  patient  voids 
will  loosen  shreds  and  slugs.  The  urine  should  be  collected  in  a  sterile 
conical  glass  and  allowed  to  sediment  by  gravitation.  The  accumula- 
tion of  the  gravitated  pus  and  detritus  is  pipetted  and  spread  upon 
the  slide.  The  urine  may  be  centrifuged  at  high  speed  for  several 
minutes  and  then  pipetted  and  the  specimen  prepared  for  the  micro- 
scope. If  the  deposit  is  excessive  it  may  be  diluted  with  normal  salt 
solution  and  again  centrifuged  or  gravitated.  After  such  dilution  the 
examination  is  much  more  easy  and  accurate. 

In  the  second  place  the  gonococcus  renders  its  discovery  in  the  urine 
difficult  because  in  nearly  cured  cases  the  other  normal  flora  of  the 
urethra  begin  to  predominate  and  the  gonococcus  is  very  scattered 
and  infrequent.  For  this  reason  many  control  specimens  are  required, 
especially  in  the  female.  A  single  negative  investigation  is  useless. 
The  Gram  stain  is  the  one  security  against  error  and  should  always  be 
made  together  with  study  of  the  morphology  and  grouping  of  the 
organisms  in  and  about  the  pus  cells.  Culture  when  possible  is  the 
best  of  all  diagnosis.  It  should  always  be  attempted  if  the  m-ine  is 
fresh  and  collected  under  antiseptic  precautions.  Of  the  other  organ- 
isms in  the  urine  the  cocci  are  the  most  important  for  consideration. 
Most  of  them  are  gram-positive  and  a  few  are  gram-negative.  The 
majority  of  these  cocci  are  very  rare  in  the  iu"inary  passages,  especially 
in  the  male.  The  reader  is  referred  to  works  on  bacteriology  for  the 
list  and  distinctions  of  these  bacteria.    The  ^Micrococcus  meningitidis 


474  GENERAL  PRIXCIPLES  OF  DIACXOSIS 

jind  Micrococcus  catarrhalis  are  important.  Of  tlu-sc  two  the  former 
is  very  rare  indeed  in  the  urinary  oruans  and  is  i'ounil  chiefly  in  the 
upjier  air  passaj::es  and  in  tlie  cerehrospinal  spaces  in  cases  of  nienin- 
ijitis.  The  Micrococcus  catarrhahs  is  more  imj)ortant  and  very  common 
in  the  rnvthra  «if  men  and  women.  In  its  early  life-cycle  it  is  gram- 
negative  and  only  later  gram-positi\-e.  In  morphoU)gy  it  resembles 
the  gonocofcus  more  than  any  other  coccus  does.  Culture  alone  is  the 
means  of  iliaynosis.  This  coccus  usually  grows  freely  at  room  tcmpera- 
tiu-e.  Further  discussion  of  this  organism  is  in  the  clinical  pages  of 
this  work  under  the  subject  of  Nongonococcal  Urethritis.  Bumm,^ 
in  his  original  work,  contributed  largely  to  our  knowledge  of  the  cul- 
tural ])c('uliaritics  of  the  gonococcus. 

Gonococcus  in  Dried  Pus.^ — The  demonstration  of  the  gonococcus  in 
stains  and  crusts  on  clothing  and  dressings  is  possible  but  very  difficult. 
The  medicolegal  aspects  of  this  detail  comprise  its  importance  as  to 
results  and  technical  performance.  The  fliagnostic  requirements  of 
the  (iram  stain  and  culture  at  once  show  its  limitations,  because  the 
gonococci  nnist  be  in  the  pus  cells  and  the  white  blood  cells  and  possess 
the  correct  form,  size,  grouping  and  staining,  as  already  shown  under 
this  subject  on  page  2().  Cultm-e  is  often  doomed  to  failure  because 
the  gont)coccus  is  not  resistant  and  dies  early  as  it  dries,  so  that  in  very 
old  stains  on  clothing  cultm-e  is  not  possible.  Other  organisms  in  the 
crust  may  easily  deceive  the  observer.  In  a  girl  who  had  been  repeat- 
edly ra\'ished  by  one  man  micrococci  were  found  by  Wachholz  and 
Xowak.-  These  resembled  the  gonococcus  very  closely,  but  both  the 
man  and  the  woman  did  not  have  the  disease.  The  error  arose,  as  it 
might  in  any  similar  case,  from  the  fact  that  not  only  the  micrococci 
api)eared  like  the  gonococcus  but  also  the  latter  changes  its  character 
in  these  old  specunens. 

There  are  two  general  methods  of  searching  such  stains,  those  of 
Kratter  and  of  Ileger-Gilbert. 

Kratter^  scraped  dried  pus  from  the  clothing,  soaked  it  in  water  for 
a  brief  period,  squeezed  threads  and  shreds  free  of  the  pus  and  made 
the  usual  smear  preparation  for  stain  and  examination.  Ilaberda,^  in 
experunenting  with  this  method,  pro\'ed  that  success  is  directly  ])ro- 
portional  to  the  amount  of  pus  and  the  cleanliness  of  the  linen;  great 
difficulties  occur  in  thin  stains  and  soiled  linen,  but  greater  certainty 
of  diagnosis  and  ease  of  technic  in  thick  stains  and  clean  linen.  These 
principles  are  self-evident  because  the  larger  the  amount  of  pus  and 
the  less  the  contamination  or  chance  thereof  the  better  the  results  of 
investigation. 

Heger-Gilbert^  demonstrated  the  gonococcus  in  a  two-year-old 
stain.    The  method  is  to  cut  a  pad  of  linen  or  blotting  paper  to  fit  a 

>  Der  Mikroorganismen  gonorrhoeischer  Schleimhaut-Erkrankungen,  Wiesbaden, 
1885. 

2  Viertelj.  f.  gerichtl.  Med.,  1895,  3  F.,  ix,  75. 

s  Berl.  klin.  Wchnschr.,  1890,  xxvii,  960. 

*  Viertelj.  f.  klin.  Med.,  1894,  3  F.,  viii,  Suppl.  Heft,  p.  227. 

-  Jour.  m6d.  de  Bruxelles,  1908,  xiii,  524. 


ORRHODfAGNOSrS  OR  HERUMDT AGNOfiTH  475 

watch-glass  and  to  moisten  it  with  isotonic  salt  solution,  alkalized 
with  sodium  bicarbonate.  The  stain  is  cut  to  size  and  plac(;d  on  this 
pad  and  covered.  After  from  one  to  five  hours  the  dnjps  underneath 
are  sucked  up  and  transferred  to  the  slide,  smeared,  dried  and  stained. 
This  is  an  accurate  method,  but  concerns  morphology  only. 

ORRHODIAGNOSIS  OR  SERUMDIAGNOSIS. 

Orrhodiagnosis. —  Definition.- — Serumdiagnosis  may  be  regarded  as 
recognition  of  disease  through  the  means  of  bacterial  j^roducts,  of  which 
serum  was  the  first  and  still  remains  the  chief,  although  it  by  no  means 
includes  all  the  products.  When  injected  into  the  animal  in  suspected 
disease,  various  reactions  occur  which  are  the  basis  of  the  diagnosis. 
Serum  therapy  may  be  described  as  the  treatment  of  disease,  similarly 
by  injection  of  bacterial  products,  of  which  serum  is  again  the  most 
typical.  Such  treatment  rests  on  protection  of  the  patient,  steadily 
augmented  by  graduated  and  ascending  doses  of  the  product. 

Basis. — In  man,  as  in  all  other  mammals  during  disease,  the  blood 
produces  protective  elements,  specific  for  each  disease,  and  known  as 
antibodies.  These  may  be,  subdivided  into  two  kinds  in  accordance 
with  their  action  on  the  organisms  themselves  and  with  their  influence 
on  the  products  of  the  organisms. 

Varieties  of  Antibody. — 

1.  Having  action  on  the  organisms  themselves: 

{a)  Agglutins,  which  cause  the  germs  to  "chunp"  or,  as  the  term 

indicates,  to  agglutinate  in  the  field  of  the  microscope  upon 

their  addition  to  the  specimen. 
(6)  Bacteriolysins,   which  dissolve    or    destroy    the    organisms 

directly. 
(c)  Opsonins  or  bacteriotropins,  which  alter  the  constitution  of 

the  organisms  so  that  the  blood  readily  disposes  of  them  by 

phagocytosis. 
(f/)  Precipitins,  which  as  the  term  suggests,  precipitate  the  germs 

in  laboratory  preparations. 

2.  Having  influence  on  the  products  of  the  organisms: 

(a)  Antitoxins,  which,  as  the  term  shows,  neutralize  or  otherwise 
influence  the  toxin  favorably  for  the  individual  infected. 

PfeifEer's  Phenomenon. — In  1896  Richard  Pfeifter^  discovered  the 
fact  that  when  the  peritoneal  fluid  of  a  guinea-pig  immunized  to  the 
cholera  bacillus  possesses  the  power  of  causing  the  destruction  and  dis- 
appearance of  living  cholera  bacillus  (bacteriolysis)  and  that  the  blood 
corpuscles  of  immimized  animals  when  added  to  the  blood  of  non- 
immunized  animals  produces  a  specific  action  called  hemolysis.  This 
discovery  was  destined  to  reveal  one  of  the  peculiar  features  of 
immunity.^ 

Immunity. — ^Immunity  may  be  briefly  regarded  as  the  condition  of 
resistance  to  a  given  disease  produced  by  the  specific  action  of  the 

1  Deutsche  med.  Wochenschrift,  1896,  Nos.  7  and  8.  ^  Chetwood,  loc.  cit. 


476  GENERAL  PRINCIPLES  OF  DIAGNOSIS 

antibodies  of  tliat  disease  in  the  blood  and  is  described  as  of  two  forms, 
active  and  ])assive.  (1 )  Active  ininuniity,  also  tcrnicd  natural  innnunity, 
directly  follows  a  disease  and  oriiiinates  in  the  i)rocesscs  of  recovery, 
including  the  development  and  action  of  antibodies  hi  the  blood  specific 
for  said  disease.  ■  (2)  Passive  hnniunity,  al-io  sonietunes  called  artificial 
innnunity,  is  induced  by  the  injection  of  the  serum  of  an  imnumized 
animal,  in  dose  determhied  by  the  disease  and  the  age  of  the  patient 
or  by  the  injection  of  bacterial  products  or  antibodies  from  the  blood 
of  animals  pre\iously  inmiunized,  beginning  with  small  and  continuing 
with  regularly  graduated  and  ascending  doses  until  resistance  to  the 
disease  is  established. 

Anaphyla.xis. — Anaphylaxis  is  the  converse  of  innnunity  and  indi- 
cates a  lowered  resistance  and  an  increased  susceptibility  to  tlie  dis- 
ease, and  is  therefore  dangerous  and  disadvantageous  to  the  patient. 
Immunity,  on  the  other  hand,  may  be  regarded  as  increased  resistance 
and  as  decreased  susceptibility,  and  is  therefore  a  protective  of  the 
patient.  The  Theobald  Smith  reaction  is  the  basis  of  anaphylaxis  and 
rests  on  the  following  facts:  If  a  small  animal,  such  as  the  guinea-pig, 
is  injected  with  a  small  measured  quantity  (1  c.c.)  of  the  blood  of  an 
animal  of  a  different  species,  such  as  the  horse,  and  if  again  after  ten 
to  fourteen  days  the  guinea-pig  is  injected  with  several  times  (3  to 
5  c.c.)  the  original  quantity  of  blood  from  the  same  animal  (horse), 
death  will  occur  in  about  one  hour,  during  symptoms  of  extreme 
severity  whose  onset  is  almost  immediately  after  the  second  injection. 
Other  proteid  substances  are  known  to  act  similarly,  especially  bac- 
terial ])roducts,  and  it  is  likely  that  death  from  snake  poisoning  at 
least  in  some  forms  belongs  in  this  class  of  phenomena. 

Serums  are  strictlv'  obtained  from  the  serum  of  immunized  animals 
by  processes  whose  description  belongs  to  works  on  bacteriology,  and 
bacterins  are  suspensions  of  inactivated  and  dead  bacteria  prepared 
in  the  laboratory.  Both  sermns  and  bacterins  are  used  by  injection 
in  the  production  of  active  and  passive  immunity.  Serum  contains  the 
protective  elements  produced  by  the  patient  in  the  establishment  of 
active  immunity  or  by  the  animal  in  the  laboratory  during  the  same 
process.  Thus  it  may  be  said  that  the  injection  of  serums  produces 
passive  immunity  by  providing  the  subject  with  protection  not  pro- 
duced by  himself.  The  infection  of  the  animal  with  organisms  in  the 
course  of  nature  or  the  injection  of  living  or  dead  organisms  or  their 
suspensions  or  emulsions,  technically  known  as  bacterins,  confers  on. 
the  other  hand  active  unmunity,  because  the  subject  must  build  up 
his  own  resistance  against  such  natural  or  artiiicial  invasion,  and  thus 
acquire  immunity.  One  might  call  them  respectively  also  conferred 
imnnuiity  and  acquired  immmiity. 

Complement  Fixation  Test. — As  already  indicated,  in  practical  use 
the  antibodies  of  greatest  service  are  (1)  the  agglutins,  familiar  in  the 
agglutination  test  of  typhoid  fever;  (2)  precipitins  whose  technical 
difficulties  rule  them  out  for  diagnosis,  but  make  them  of  value  in 
medicolegal  work,  and  (3)  bacteriolysins  and  hemolysins.     Pfeiffer 


ORRHODIAGNOSIS  OR  SERUMDIAGNO.VS  477 

was  the  first  to  demonstrate  that  the  blood  has  a  direct  destructive 
action  on  organisms,  which  he  discovered  from  the  fact  that  the  peri- 
toneal serum' from  a  guinea-pig  immunized  to  cholera  possesses  the 
power  of  causing  both  the  death  and  disappearance  of  living  cholera 
bacilli — in  other  words,  the  j)ower  of  bacteriolysis.  Pfeifi'er  further- 
more showed  that  the  corpuscles  from  the  bloorl  of  an  immunized 
animal  when  injected  into  another  animal  produced  the  specific 
hemolysis  or  destruction  pf  the  red  cells,  a  phenomenon  which  is  desig- 
nated by  the  term  hemolysis.  If  serum  from  an  immunized  animal 
containing  hemolytic  elements,  technically  known  as  amboceptor,  is 
raised  to  54°  C.  for  thirty  minutes  or  kept  for  several  days  at  room 
temperature  it  is  inactivated.  The  serum  of  an  animal  which  is  not 
immune,  of  either  identical  or  other  species,  may  be  added  fresh  to 
the  inactive  serum  for  restoration  of  activity.  Such  restorative  or 
reactive  element  is  called  complement.  Two  substances  are  therefore 
necessary  for  hemolysis,  first  a  hemolysin  or  amboceptor,  which  is  a 
specific  body  produced  by  the  processes  of  immunization  and  rendered 
stable  by  exposure  to  temperature  of  less  than  60°  C,  and  second  a 
complement,  which  is  a  nonspecific  body  contained  in  the  serum  of  a 
nonunmunized  animal. 

Complement  fixation  tests  are  in  common  use  in  syphilis  and  gono- 
coccal urethritis,  and  in  less  frequent  use  in  echinococcus  infections 
and  in  experimental,  and  as  yet  unsatisfactory  application  in  tuber- 
culosis. It  is  possible  that  with  time  a  large  number  of  diseases  will 
be  brought  within  the  diagnostic  value  of  this  test. 

Preparation  of  Blood  Specimen. — The  instruments  and  supplies 
required  are:  (1)  for  the  field,  sterilized  towels,  sw^abs,  soap,  alcohol 
and  iodin  and  (2)  for  the  surgeon,  sterile  gown  or  apron,  needles  with 
stylets,  file,  bottles  or  tubes  with  stoppers  of  cotton  or  cork  or  the 
means  of  hermetical  seal  and  tourniquet.  That  arm  of  the  patient  is 
chosen  having  the  best  size  and  distribution  of  veins.  The  subject  is 
placed  on  the  table  as  a  precaution  against  fainting,  with  the  sleeve 
of  the  chosen  arm  rolled  to  the  arm-pit.  The  surgeon  washes  and 
sterilizes  his  hands  while  the  nurse  prepares  the  skin  of  the  patient  by 
scrubbing  the  flexor  aspect  of  the  elbow  for  several  inches  above  and 
below  it,  applies  the  tourniquet  and  places  the  towels  on  the  upper 
arm,  forearm  and  table  and  arranges  the  instruments  for  the  surgeon's 
convenience.  The  patient  clenches  his  fist  firmly,  which  not  only 
squeezes  the  blood  from  the  muscles  into  the  veins  of  the  skin  but  also 
aids  in  fixing  the  veins.  The  surgeon  accepts  the  most  prominent  and 
accessible  vein,  steadies  the  skin  over  it  by  downward  traction  and 
inserts  the  needle  quickly  with  the  bevel  of  the  point  upward  so  as 
to  engage  the  surface  of  the  vein  instead  of  pushing  it  ^side.  The  needle 
should  be  proportional  with  the  size  of  the  vein  and  after  penetration 
is  slid  into  the  cavity  of  the  vessel  for  perhaps  a  centimeter.  The  test- 
tube  or  bottle  is  applied  to  the  outlet  of  the  needle  the  instant  blood 
appears,  preferably  by  the  assistant  or  nm-se,  as  both  the  surgeon's 
hands  are  usually  engaged,    Active  flow  or  pumping  of  the  blood  is 


47S  GENERAL  PRINCIPLES  OF  DIAGNOSIS 

obtained  by  liaxins,^  the  patient  at  intei-A'als  of  e\'ery  few  seconds 
slowly  oi)en  and  deliberately  and  forcibly  close  liis  fist,  thus  i)ressing 
the  blood  from  the  depths  of  the  muscle  planes  to  the  veins  of  the  skin. 
The  (luantity  of  blood  absolutely  necessary  is  about  5  c.c.  or  I  dram, 
but  because  many  si)eeimens  re([uire  more  than  one  examination  in 
difficult  cases  as  controls  it  is  well  to  secure  L5  c.c.  The  preservation  of 
the  blood  is  most  hnportant  and  is  secured  by  aseptic  precautions  and 
immediate  corking  or  sealing  of  the  tube  and  then  by  j)lacing  them  in 
an  ice-box.  It  may  be  allowed  to  stand  for  separation  of  the  serum  in 
the  ice-box  or  centrifuged  before  being  placed  there.  These  details 
rest  with  the  laboratory  expert  and  cannot  be  carried  out  by  the  prac- 
titioner, who  rarely  has  suitable  facilities.  The  transportation  of  the 
specimen  is  often  an  obstacle  of  success  because  the  blood  or  serum 
nuist  be  sealed  hermetically  and  delivery  secured  in  twenty-four  hours. 
Hot  weather  augments,  cold  weather  decreases  these  difficulties. 
The  tendency  is  therefore  in  many  States  for  each  county  to  have  one 
or  more  State  laboratories  and  for  even  small  hospitals  to  equip  the 
same  in  order  to  overcome  these  problems. 

Laboratory  Technic. — These  complement  fixation  tests  are  so  refined 
and  difficult  that  they  belong  to  the  specialist  in  the  laboratory 
field  and  cannot  be  wisely  undertaken  by  the  family  practitioner, 
urologist  or  surgeon  who  cannot  possibly  possess  the  necessary  special 
training  or  afford  the  time  for  the  observation  of  individual  tests,  their 
repetitions  and  controls.  In  addition  to  this  personal  equation  on  the 
part  of  the  operator,  extensive  apparatus  is  required  exemplified  by 
ice-chests,  incubators,  water-baths,  centrifuges,  glassware,  racks  and 
the  like  and  added  to  these  animal  cages  and  runs  for  large  numbers 
of  guinea-pigs  for  the  complement  and  rabbits  immunized  against  the 
blood  of  sheep  for  the  amboceptor.  Access  to  a  slaughter  house  at  which 
perfectly  fresh,  sterile  sheep's  blood  may  be  copiously  obtained  is  also 
essential. 

Limitations  of  Laboratory  Findings.^A'arious  contradictions  seem  to 
Ix'  present  in  the  results  of  complement  fixation  work  in  the  hands  of 
different  laobratories  and  the  demand  is  increasing  for  standardized 
elements,  methods  and  reports  and  it  is  likely  that  in  time  a  central 
authority  like  the  Board  of  Health  of  cities  and  States  will  undertake 
the  production  of  elements  of  standard  valence  which  will  be  employed 
by  all  workers  and  thus  will  secure  less  contradictory  if  not  fully  uni- 
form results.  These  restrictions  apply  to  all  laboratory  work  of  the 
refined  order  of  complement  fixation  tests  but  for  our  purposes  interest 
centers  in  that  for  gonococcal  infection.  For  these  Tcasons  the  author 
belie^'es  that,  in  cases  of  doubt  wlierein  laboratory  reports  are  at 
^•ariance  with  clinical  observation,  a  control  specimen  should  be  sent 
to  the  same  laboratory  for  a  second  test  and  from  the  same  quantity  of 
blood  at  least  two  other  laboratories  of  high  order  should  receive 
specimens.    Thereafter  the  a\'erage  opinion  is  the  one  to  be  accepted. 

Gonococcal  Complement  Fixation  Test. — Basis. — The  bacteriological 
and    hemol}i;ic    principles    underlying    the    gonococcal    complement 


RESULTS  OF  TREATMENT  479 

fixation  test  are  the  same  as  tliosf;  f^(^ii(!ral)y  ;w;(;(;|)t(!d  for  the  sypfiilitic 
or  Wassermann  reaetioii.  It  is  known  as  a  fully  accepterl  eiinical  fae-t, 
however,  that  the  gonococcus  occurs  in  a  number  of  strains  which 
vary  from  each  other  in  virulence.  Bacteriologists  are  not  able  to 
distinguish  these  strains  with  promptness  on  account  of  the  clifficulty 
of  culturing  the  organism,  so  that  in  the  complement  reactirjii  of  this 
disease  it  is  necessary  to  use  a  polyvalent  antigen  made  up  of  a  large 
number  of  strains.  The  greater  this  number  the  better,  so  that  10,  12 
or  15  strains  are  now  regarded  as  the  most  satisfactory  combination, 
for  certainty  of  including  the  given  strain  of  gonococcus  present  in  the 
patient.  It  would  otherwise  be  necessary  to  isolate  and  recognize  this 
strain  and  employ  it  in  producing  the  antigen. 

Occurrence. — The  gonococcal  complement  fixation  test  is  less  con- 
stant and  less  reliable  on  the  whole  than  is  the  Wassermann  reaction 
in  syphilis.  It  is  said  never  to  occur  in  both  sexes  before  the  disease 
has  existed  in  its  florid  state  for  some  time.  Its  most  constant  presence 
is  in  the  chronic  manifestations  within  the  urethra  and  in  the  profound 
and  chronic  complications.  It  is  therefore  seen  in  the  male  in  persistent 
chronic  urethritis,  prostatitis,  seminal  vesiculitis,  and  in  the  female  in 
endometritis,  pus  tube,  ovarian  abscess  and  arthritis,  as  examples, 
proceeding  from  absorption  in  pus  pockets  in  these  lesions.  When 
the  gonococcus  is  present  beyond  doubt,  this  reaction  is  positive  in 
about  100  per  cent,  of  the  cases  examined  and  when  a  history  of  pre- 
vious gonococcal  infection  is  definite  its  satisfactory  reports  are  also 
numerous.  Schwartz  and  McNeal^  did  much  of  the  original  research 
work  in  this  field  and  give  the  following  table  of  results : 

No.  of 
cases. 
Chronic  urethritis  of  gonorrheal  origin: 

(a)  Gonococci  present 4 

(b)  Gonococci  not  found 36 

(c)  Examination  for  gonococci  made       ...        8 
Chronic  prostatitis: 

(a)  Gonorrheal  history 25 

(b)  Gonorrheal  history  doubtful 2 

Joint  affections: 

(a)   Gonorrheal  arthritis 14 

(6)    Gonorrheal  arthritis  questionable      ...        7 

(c)  Other  joint  affections 9 

RESULTS  OF  TREATMENT. 

In  the  introductory  paragraph  of  this  chapter  the  results  of  treat- 
ment were  distinctly  described  as  a  fourth  element  in  the  diagnosis 
of  a  given  case.  On  the  one  hand,  while  this  dictum  in  the  case 
of  gonococcal  disease  is  not  as  fully  true  as  it  is  in  the  case  of  surgery 
and  some  conditions  of  medicine  wherein  exploration  reveals  the  exact 
diagnosis  and  furnishes  specimens  for  pathological  proof,  on  the  other 
hand,  properly  balanced  treatment  which  necessarily  involves  careful 

1  Jour.  Am.  Med.  Assoc,  May,  1911. 


Positives, 

SIo. 

per  cent. 

4 

100 

27 

SO 

7 

90 

17 

67 

1 

50 

14 

100 

4 

57 

1 

11 

480  CEXERAL  FIUXCIPLES  OF  DLWyOSIS 

exi)loration  of  a  given  case  at  repoateil  inter\als  does  reveal  the  exact 
refiiieinents  of  diagnosis.  lU'ctal  treatment  will  elicit  foci  of  infection 
in  the  jirostate,  ditferencos  between  the  two  seminal  vesicles  and  nre- 
thral  exjjloration  with  finger  and  instrmnents  and  the  urethroscope 
will  invariably  define  conditions  which  would  otherwise  escape  recogni- 
tion. Beyond  these  generalizations  one  ma.N'  not  ])ass  in  a  work  of  this 
size,  but  the  relation  of  treatment  to  final  diagnosis  is  at  once  apparent, 
because  many  of  these  details  of  diagnosis  are  matters  of  development 
and  observation  during  treatment. 

Urethroscopy  in  diagnosis  and  in  treatment  is  so  ^■ast  a  subject 
that  like  cystoscopy  it  is  treated  in  a  separate  chapter. 


DIAGNOSIS  OF  ACUTE  AND  CHRONIC  COMPLICATIONS. 

Genital  and  Urinary  Groups. — General  Principles. — The  preceding 
paragraphs  arc  concerned  with  the  establishment  of  the  fact  of  gono- 
coccal invasion  to  the  exclusion  of  other  infections,  and  its  diagnostic 
principles  Avere  laid  down  as  four  elements.  In  the  recognition  of  gono- 
coccal com])lications,  the  data  of  history,  symptoms,  laboratory  inves- 
tigation and  treatment  must  also  be  elicited  and  deductions  therefrom 
reached.  During  gonococcal  disease,  as  already  shown  in  the  chapters 
on  complications,  the  incidence  of  the  complications  is  either  in  the 
genital  and  m-inary  groups  or  the  extragenital  grouji  of  organs.  Com- 
plications arising  in  the  urogenital  system  may  be  said  to  do  so  by 
subsequence  or  by  concurrence,  because  one  sees  as  a  rule  first  the 
urethral  involvement  as  the  primary  focus  followed  by  the  complica- 
tion as  the  secondary  or  subsequent  focus  and  as  a  less  frequent  experi- 
ence the  urethritis  and  its  complication  arise  practically  together  as 
concurrents.  Examples  of  the  latter  are  urethritis,  accompanied  by 
phimosis  and  balanoposthitis  in  the  acute  disease  and  relapses  of  chronic 
disease  in  which  several  organs  may  be  simultaneously  involved,  such 
as  the  urethra,  prostate,  testicles  and  seminal  vesicles. 

Extragenital  Group. — Complications  appearing  in  the  extragenital 
groups  of  organs  may  be  coincidences,  because  an  entirely  different 
disease  may  invade  the  patient  during  his  urethritis  exactly  as  he  may 
fall  and  break  his  leg  during  his  urethritis.  Thus  in  this  group  the 
diagnosis  must  be  very  carefully  established  in  order  to  aA'oid  error 
especially  when  such  complications  are  of  the  more  rare  forms  by 
metastasis. 

The  determination  in  both  groups  must  include  physical  examina- 
tion, urethroscopy,  cystoscopy,  urinalysis,  blood  tests,  and  bacterio- 
logic  smears  and  cultures. 

Diagnosis  in  the  Female. —  General  jjrinciples  are  the  same  as  those 
discussed  in  the  male  and  are  a  careful  history,  minute  physical 
examination,  full  laboratory  investigation  and  often  the  results  of 
treatment  before  absolute  judgment  is  reached.  The  essentials  are 
the  same  in  comprising  repeated  specimens  properly  collected  and 


DIAGNOSIS  OF  ACUTE  AND  CHRONIC  COMPLICATIONS      481 

prepared,  careful  difrercntial  staining,  timetaking  search,  culture  and 
blood  test. 

The  sites  of  infection  are  the  urethra,  vulva  and  vagina  in  the  early 
cases  and  later,  as  already  stated,  in  ascending  order  the  other  mucosae 
of  the  sexual  tract  in  extending  cases  and  the  mucosae  of  the  urinary 
tract  and  extragenital  tracts  in  the  complicated  forms.  The  sites  for 
specimens  are  the  urethra,  the  vulvovaginal  glands,  the  posterior 
fornix  of  the  vagina  and  the  lower  cavity  of  the  cervix.  The  author 
prefers  to  collect  two  slides  from  each  of  these  points  and  recognizes 
that  specimens  of  little  value  are  obtained  from  the  female  quiescent 
which  means  the  condition  of  the  patient  for  ordinary  investigation  in 
institution  or  office  but  that  preparations  of  great  value  are  secured 
from  the  female  stimulated,  which  means  through  the  period  of  physio- 
logical hyperemia  and  increased  discharge,  immediately  before  or  after 
menses,  during  the  late  decline  of  lochia  after  miscarriage  or  childbirth, 
during  sexual  desire  and  in  alcoholism,  and  through  the  period  of  arti- 
ficial congestion  and  exudate  after  the  local  application  of  stimulants, 
such  as  10  per  cent,  nitrate  of  silver  or  massage,  respectively  leading 
to  superficial  irritation,  desquamation  and  discharge  and  to  glandular 
evacuation  by  pressure  and  manipulation.  The  hollow  of  the  blades 
of  the  bivalve  speculum  will  often  receive  from  the  cervix  or  wall  of 
the  vagina  a  valuable  specimen  which  should  be  added  to  the  slides 
already  secured.  About  forty-eight  hours  must  elapse  between  the 
application  of  the  mild  caustic  and  the  taking  of  the  specimen,  other- 
wise no  organisms  will  be  found  through  the  destructive  quality  of  the 
solution. 

In  the  urethra,  after  washing  the  vestibule  with  cotton  and  boric 
acid  water,  nitrate  of  silver  10  per  cent,  may  be  swabbed  or  instillated 
into  the  lower  canal  and  specimens  taken  on  the  second  day.  By 
the  vaginal  touch  two  fingers  are  placed  in  the  vagina  supporting  the 
canal  and  drawn  forward  with  firm  pressure  against  the  arch  of  the 
symphysis,  literally  "milking"  the  mucosa  of  all  glandular  contents 
and  exudate  upon  its  surface.  In  the  other  hand  the  operator  has 
a  sterile  swab  ready  for  wiping  off  the  discharge  and  transferring  it 
to  microscopic  slides.  Skene's  glands  are  most  important  and  are 
evacuated  with  two  fingers  in  the  vagina  to  steady  the  urethra  and  a 
common  sterilized  hairpin  drawn  over  each  gland  with  pressure  against 
each  finger  in  turn.    The  drop  of  pus  is  secm-ed  on  a  swab  for  the  slide. 

In  the  vestibular  or  vulvovaginal  glands,  after  cleansing  the  vesti- 
bule and  labia,  one  or  two  fingers  are  inserted  into  the  vagina  while 
the  thumb  of  the  same  hand  or  two  fingers  of  the  opposite  hand  gently 
squeeze  the  gland  until  exudate  appears.  The  drop  of  pus  is  received 
on  a  swab  or  du-ectly  on  a  slide.  Sometimes  the  ducts  of  these  glands 
will  permit  a  small  platiniun  loop  to  be  mserted. 

In  the  posterior  fornix  of  the  vagina,  after  washing  off  the  ^'^llva,  a 

speculiun  without  lubricant  other  than  water  is  gently  inserted  and 

opened  so  as  to  bring  the  cervix  and  fornix  well  under  control.    The 

specimen  may  be  secured  with  the  swab  or  platiniun  loop  directly  or 

31 


4S2  GENERAL  PRiyCIPLES  OF  DIAGXOSIS 

after  gentle  curettement  with  a  hairpin  in  a  heniost^it.  In  cases  of 
doubt  the  vavilt  of  the  vagina  is  nioi)i)e(l  Hberally  with  10  per  cent. 
nitrate  of  silver  at  the  first  visit  and  on  the  seeond  day  when  the  intense 
reaction  and  the  destruction  of  organisms  have  ceased  the  si)ecinien  is 
taken. 

In  the  cervix  lies  one  of  the  most  uni)ortant  foci  and,  in  acknowledged 
infeetion,  negative  specimens  must  be  nimierons  and  consistent  for 
])roof  of  cure.  The  glands  may  be  expressed  by  massage  with  the  fingers 
in  sterile  gloves  or  by  gentle  ililatation  with  a  small-si/.ed  (n)odell 
dilator  or  by  gentle  ciu-ettement  with  a  hairpin  in  the  jaws  of  a  clamp. 
The  drop  is  taken  u]>  with  a  platiniun  loop  or  sterile  swab.  The  period 
of  i>]iysiological  Inperemia  and  discharge  incident  to  the  menses, 
postpartum  conditions,  sexual  excitement  or  intercourse  and  the  period 
of  artificial  congestion  after  swabbing  with  nitrate  of  sihcr  are  ])ro- 
pitious  for  successful  specimens. 

The  time  for  specimens,  as  in  the  male,  is  the  early  morning,  because 
then  the  lu-ethra  contains  accunnilated  mucus  which  should  not  be 
cleansed  by  urination  before  the  test;  because  then  the  cervix  has 
filled  the  posterior  fornix  with  its  discharge,  which  should  not  be 
removed  by  douche  or  allowed  to  escape  by  much  bodily  activity;  and 
ijecause  then  the  \-uh-o vaginal  glands  if  draining  are  full  after  the 
recumbent  position  of  sleep.  There  should,  therefore,  be  no  urination, 
no  defecation  and  no  douche  from  the  night  before  to  the  morning  of 
examination.  If  the  patient  eats  a  light  cN-ening  meal  and  partakes 
of  little  fiuid  dm-ing  the  evening  these  restrictions  are  easily  obeyed. 

These  special  features  apply  to  the  female.  All  the  general  features 
are  alike  in  both  sexes. 


CHAPTER    IX. 

GENERAL  PRINCIPLES  OI^"  TPvEA^rMK\^J\ 

Treatment  should  be  discussed  under  a  number  of  headings,  no 
matter  what  the  disease  under  consideration  is.  These  headings  are 
commonly  accepted  in  gonococcal  disease  as:  proi)h>']axis,  both  per- 
sonal and  social,  abortive  measures,  palliation,  curative  measures 
both  expectant  and  irrigative,  management,  medicinal  and  surgical 
means.  Sharp  lines  of  distinction  are  not  possible  because  methods 
under  one  heading  may  in  their  application  and  effects  pass  over  into 
another  heading.  In  general,  curative  measures  are  those  which  are 
directly  applied  to  the  infection  by  the  gonococcus  in  the  local  urethritis 
or  its  complications  or  in  systemic  effect  when  such  arises.  In  this 
sense  all  other  measures  are  palliative  in  that  they  soothe  the  patient 
and  relieve  his  symptoms  with  only  indirect  effect  on  the  infection. 

PREVENTIVE  TREATMENT. 

Varieties. — Prevention  of  an  acquired  disease  like  urethritis  is  two- 
fold— personal,  relating  to  the  patient  himself  and  social,  concerning 
his  associates  at  home  and  abroad. 

Personal  Prophylaxis. — Significance. — Personal  prophylaxis  is  justi- 
fied and  required  in  order  to  protect  the  individual  as  far  as  possible 
against  the  social  conditions  and  the  high  cost  of  living  whidi  remotely 
postpone  or  even  absolutely  prevent  marriage  at  that  time  of  life  when 
Nature  intended  it  should  occur.  Thus  there  arises  the  temptation 
and  the  means  of  sexual  promiscuity  and  immorality  which  the  incon- 
tinent in  both  sexes  do  not  resist  and  in  a  certain  sense  can  hardly 
be  expected  to  resist,  no  matter  how  much  these  sad  facts  may  be 
lamented.  The  dictmn  often  heard,  therefore,  that  such  persons 
should  be  penalized  by  the  results  of  their  indiscretions  is  both  unrea- 
sonable and  unfair,  just  as  much  as  would  be  the  dictmn  that  the 
victims  of  tuberculosis  should  receive  no  aid  because  they  often  live 
in  squalor,  which  is  a  potent  source  of  tuberculosis.  The  T\Titer  has 
never  found  a  man  or  woman  the  victim  of  venereal  disease  and  having 
a  reasonable  normal  view  of  life  who  did  not  regi'et  this  situation  and 
state  that  marriage  with  an  individual  fulfilling  other  relations,  attrac- 
tions and  happiness  than  the  merely  sexual  tie  would  be  much  prefer- 
able to  promiscuity  and  immorality.  In  other  words,  therefore,  the 
home  and  parental  instinct  and  the  spirit  of  devotion  to  one  hiunan 
being  is  after  all  predominant  but  cannot  often  be  satisfied  in  present 
social  conditions  for  which  society  is  responsible  and  against  which 
society  must  furnish  protection  to  the  individual,  as  far  as  possible. 

In  children,  gonococcal  infection  is  somewhat  more  common  in  girls 


484  GEXERAL  PRIXCIPLES  OF  TREATMENT 

than  in  boys  because  in  the  use  of  the  (liai)er  the  sexual  organs  beinc; 
wide  open  in  the  female  are  very  easily  infected  from  the  fingers  of 
attendants  and  utensils,  as  is  evidenced  by  epidemics  of  vaginitis  in 
institutions,  usually  of  specific  t^'pe.  The  results  thereof  are  often 
endometritis,  infantile  uterus  and  sterility — abundant  grounds  for 
personal  ])ro])hylaxis.  Infection  of  the  eyes  in  children  belongs  more 
properly  to  the  subject  of  social  jH-ophylaxis  (see  page  4S()).  Balano- 
posthitis  and  urethritis  in  young  boys  is  often  of  gonococcal  origin  and 
may  lead  to  devastating  se(|uels  in  their  sexual  and  urinary  systems. 
Again  proi)hylaxis  is  required. 

In  females  the  damage  of  the  internal  sexual  organs — ovaries,  tubes 
and  womb — by  the  essentially  destructive  character  of  gonococcal 
invasion  leads  either  to  unsexing  operations  for  the  removal  of  these 
organs  in  order  to  save  life  or  to  prevent  years  of  marked  iuN'alidisin 
or  to  a\oid  relati\'e  sterilit>'  in  that  stenoses,  torsions  and  other  defornn'- 
ties  of  the  tubes  and  niunerous  profound  inflammatory  changes  in  the 
ovaries  and  the  uterus  pre^'ent  the  ovum  from  reaching  the  womb  and 
pregnancy  from  occurring,  although  the  organs  may  have  otherwise 
recovered  from  the  initial  invasion.  Personal  ]irophylaxis  for  the 
woman  shoukl  therefore  be  aimed  at,  a\'oi(ling  this  damage  and  loss 
of  health.  Ascent  of  the  disease  into  the  bladder  and  kidneys  is  another 
important  thing  for  preventive  measures. 

In  males  the  infection  all  too  frequently  travels  from  the  urethra 
into  the  prostate,  seminal  \esicles,  ^'asa  deferentia,  e])idiflymes  and 
testes,  where,  as  in  the  woman,  they  often  lead  to  unsexing  sequels  so 
that  many  men  who  have  recovered  from  the  infection  and  may  safely 
marry  are  sterile,  although  the  presence  of  their  testes  permits  inter- 
coiU"se  in  the  normal  frequency  and  energy  but  without  the  normal 
physiologic  impregnating  power.  The  infection  may  pass  into  the 
urinary  organs — bladder,  ureters  and  kidneys — and  by  damaging 
them  beyond  cure  incapacitate  the  man  during  a  life  usually  much 
shortened  by  these  lesions. 

Technic. — Ignorance  of  the  nature  of  his  disease  on  the  part  of  the 
patient,  male  or  female,  is  met  by  instruction  preferably  throng] i 
printed  pamphlets  or  leaflets  which  should  cover  at  least  the  following 
points — the  bacterial  nature  and  communicability  of  the  disease,  the 
obscurity  and  persistence  of  chronic  infection,  the  cautions  in  personal 
care,  management  and  treatment  under  the  physician's  guidance  and 
the  responsibilities  for  infection  of  the  innocent  tlii'ough  dressings  and 
utensils  and  sexual  relations  particularly  in  wedlock. 

Normal  intercourse  is  essential  with  prom]3t  ejaculation  and  without 
prolonged  and  unnatiu'al  excitation  and  without  frequent  rcj^etition 
and  finally  without  delays  ^•oluntarily  produced  or  proceeding  from 
physical  exhaustion  or  inebriety.  The  gonococcus  grows  on  an  alka- 
line medium  which  is  advantageously  produced  by  the  outpouring  of 
mucus  into  the  urethra  from  the  mucous  glands  during  erection.  This 
alkalinity  may  be^largely  neutralized  and  the  gonococcus  removed 
with  the  mucus  by  the  acidity  of  the  urine.    It  is,  therefore,  well  to 


PREVENTIVE  TREATMENT  485 

have  intercourse  when  the  bbulder  is  partially  or  completely  full  of 
urine  and  to  urinate  immediately  after  the  act.  in  the  female  a  douche 
before  intercourse  is  a  protection  to  the  male  and  one  after  it  is  a  safe- 
guard to  herself.  Abstinence  from  intercourse  with  women  just  before 
and  just  after  their  menstrual  flow  is  important  because  the  congestion 
of  these  periods  often  brings  gonococci  to  the  front  which  are  otherwise 
not  inocuable  and  because  many  women  who  have  no  gonococcal 
infection  are  at  this  period  very  acrid  and  may  excite  a  chemical  rather 
than  a  bacterial  urethritis. 

The  condom  or  cover  at  once  departs  from  the  principle  of  natural 
intercourse  but  it  is  a  good  safeguard  provided  it  does  not  tear  or  break, 
There  is  a  great  prejudice  against  its  use  among  men  on  the  ground  that 
it  reduces  the  pleasure  and  injures  them  and  by  women  on  the  former 
ground  and  that  of  dryness  and  discomfort.  It  certainly  prevents 
sensation  exactly  as  a  glove  on  the  hand  limits  perception  of  the  quality 
of  material  in  shopping,  for  example;  but  when  the  glove  is  removed 
from  the  hand  the  sense  of  touch  is  shown  to  be  unaffected  and  no 
injury  to  have  resulted  to  it  by  the  wearing  of  the  glove.  On  the  same 
basis,  when  the  condom  is  not  used  sensation  in  each  sex  is  shown  to 
be  unimpaired  and  no  injury  thereto  to  have  followed  its  previous 
employment.  This  argument  is  an  axiom  but  a  most  difficult  one  for 
the  laity  to  accept.  There  is  no  question,  however,  that  the  condom 
is  uncomfortable  even  when  lubricated  but  it  remains  the  best  single 
preventive  known,  although  Luys^  dismisses  it  with  these  words: 
"It  is  said  to  be  a  kind  of  cobweb  against  the  danger,  and  an  armour 
against  pleasure." 

Treatment  of  the  male  after  coitus  should  be  taught  as  essential  and 
consists  in  calling  at  the  physician's  office  within  twelve  hours  when 
smear  and  culture  specimens  must  be  carefully  taken.  The  method  of  a 
single  application  of  1  to  3  per  cent,  nitrate  of  silver  within  the  first 
few  inches  of  the  urethra  or  the  irrigation  of  the  same  region  with 
antiseptics  or  the  instillation  and  sealing  of  the  same  in  the  canal 
as  described  under  Abortive  Treatment  on  page  49,  may  be  carried 
out.  The  patient  may  be  given  a  mild  hand  injection  of  3  to  5  per 
cent,  argyrol  or  0.5  to  1  per  cent,  protargol  two  or  three  times  a  day 
for  the  first  three  days.  Immediately  after  intercourse  the  penis  should 
be  washed  with  soap  and  water,  especially  if  the  foreskin  is  long, 
and  on  reaching  home  unmersed  in  a  glass  of  hot  antiseptic  5  or  10 
per  cent,  argyrol  or  1  to  2  per  cent,  protargol  solution  at  about  105°  to 
110°  F.,  and  these  as  hand  injections  may  be  contmued  for  two  or  three 
days.  At  the  end  of  this  period  specimens  should  again  be  taken  from 
the  mild  catarrhal  inflammation  apt  to  be  excited  by  these  steps.  If 
the  organisms  are  present,  then  the  systematic  regular  treatment  must 
be  instituted.  The  author  has  frequently  prevented  infection  by  these 
personal  prophylactic  measures  and  believes  that  they  will  not  fail  if 
carried  out  within  twelve  hours  of  sexual  congress. 

1  Text-book  on  Gonorrhea,  English  edition,  1913,  p.  271. 


486  OEXERAL  PRIXCIPLES  OF  T  RE  ATM  EN  T 

Treatment  of  the  female  after  coitus  is  alon^-  oxartly  the  same  lines 
within  t\\el\('  honrs  of  a  suspicions  inteivourse.  The  method  of  one 
apjilication  of  1  to  li  per  cent,  nitrate  of  silver  to  the  vulva,  urethra, 
vagina  and  eer\i.\  may  be  done  with  less  pain  than  in  the  male,  because 
the  nuicosa  is  less  sensitive,  or  the  external  organs  may  be  thoroughly 
washed  with  soap  antl  water  and  douched  with  a  pitcher  full  of  1  to 
201)0  potassium  permanijanate  solution  followeil  by  irrigation  of  the 
vagina  with  a  gallon  of  the  same  solution  at  110°  F.  in  the  lying  down 
position.  The  urethra  had  best  always  be  swab])ed  with  1  per  cent, 
nitrate  of  silver.  Attention  to  the  external  organs  with  the  douches 
should  be  rei)eated  from  two  to  four  times  a  day  for  three  days  and 
swabbing  the  urethra  each  day  or  every  other  day  of  the  same  period. 
The  preliminary  smear  and  culture  findings  must  be  repeated  at  the 
end  of  this  time  and  if  then  positive  the  standard  contimied  treatment 
should  i)e  at  once  instituted.  The  author  has  had  the  pri\ilege  of 
pre^•enting  the  extension  of  a  nmnber  of  infections  innocently  acquired 
in  wedlock  by  these  procedures,  so  that  the  time  and  energy  are  alike 
worth  while  for  patient  and  physician. 

Treatment  of  children  after  coitus  is  extremely  rare  because  knowledge 
of  it  does  not  appear  until  the  disease  is  established.  Rape  of  female 
children  and  forcible  intercourse  of  women  Avith  boys  are  not  so 
uncommon.  The  methods  described  for  adults  of  both  sexes  must  be 
suitably  modified  for  the  children. 

Syphilis  and  chancroids  nnist  not  be  forgotten  as  possibilities  ecjually 
with  gonococcal  urethritis.  Fortunately,  the  organisms  of  these  two 
diseases  are  slow  in  their  invasion  and  rather  vulnerable  in  their 
character  so  that  the  measures  against  the  gonococcus  are  usually 
sufficient,  especially  the  soap  and  water  cleansing  and  the  penile  bath 
and  \uh'ar  douche.  Ammoniated  mercurial  ointment  or  mercurial 
ointment  may  be  applied  in  addition  for  the  first  twenty-four  or  forty- 
eight  hours,  secured  by  a  suitable  dressing  in  each  sex,  while  the  other 
prophylaxis  is  being  done. 

Social  Prophylaxis. — Importance. — Social  jjrophylaxis  is  essential  for 
the  protection  of  society  against  the  spread  of  gonococcal  and  other 
venereal  diseases  among  the  innocent  which  may  occur  from  unsus- 
pected infections  existing  in  supposedly  cured  patients,  as  well  as  from 
more  or  less  deliberate  and  vicious  inoculation.  Children,  women  and 
men  are  alike  concerned  in  this  matter  and  for  each  the  sociologic 
importance  is  obvious  Avhen  the  history  of  infectious  diseases  is  remem- 
bered in  the  light  of  modern  bacteriology. 

In  children  blinflness  of  the  newborn  was  a  very  common  disease, 
especially  in  institutions  and  among  the  poor,  before  Crede  evolved  the 
simple  expedient  of  sterilizing  the  conjuncti\'je  of  all  infants  at  birth 
with  1  per  cent,  watery  solution  of  silver  nitrate,  wdth  normal  salt 
solution  instillations  to  allay  the  secondary  irritation.  Destruction 
of  the  gonococcus  rubbed  into  the  eyes  of  the  babies  during  birth  was 
thus  mimediatc  within  the  conjunctiva'  and  cleaulincss  of  the  skin 
prevented  reinoculation  from  the  face.    Similarly  in  children  the  first 


PREVENTIVE  TREATMENT  487 

sign  of  vaginitis  or  of  balanoposthitis  ro(juires  })act(;rio]ogic  investiga- 
tion and  prophylaxis  for  the  protection  of  the  other  meinhers  of  the 
household  or  ward. 

In  females  inno(,'ent  infection  occurs  by  husl)ands  (lis(;}Kirged  as  cured 
or  otherwise  ignorantly  the  source  of  disease  and  the  extension  of  the 
infection  in  continuity  from  the  external  organs  to  the  ovaries  with 
almost  invariable  unsexing  of  the  patient  makes  the  disease  very  serious. 
Conversely,  women  who  were  infected  in  a  life  of  immorality  from  which 
they  have  reformed  or  in  a  previous  marriage  may  in  the  same  way 
unsuspectingly  infect  their  husbands.  In  the  former  circumstances 
such  women  usually  belong  to  the  supposedly  cured  class  and  in  the 
latter  often  to  those  who  never  knew  anything  of  their  original  malady, 
although  treated  and  " cured."  Society  should  adopt  steps  to  make 
such  cases  more  and  more  uncommon  if  not  unknown.  Finally,  there 
is.  the  woman  who  as  a  professional  prostitute  intentionally  and 
deliberately  infects  everyone  she  meets,  against  whom  society  should 
also  evolve  regulations  of  sanitary  character  although  absolute  pre- 
vention is  impossible.  The  author  cannot  see  the  sociologic  sense  of 
declaring  such  laws  unconstitutional  simply  because  venereal,  wrongly 
called  private,  diseases  are  involved.  The  carrier  of  any  infection,  no 
matter  what  system  of  organs  it  compromises  and  no  matter  how  it 
was  acquired,  is  a  source  of  danger  to  the  community  economically, 
socially  and  personally.  The  carrier  of  venereal  disease  should  not  be 
allowed  unrestrained  license  to  spread  it  any  more  than  the  victim  of 
scarlatina  and  it  is  probable  that  in  time  society  will  wake  up  to  this 
responsibility  and  treat  the  victim  of  venereal  disease  in  either  sex  by 
segregation  as  the  first  step.  It  is  certainly  almost  criminal  to  say 
that  the  prostitute  should  spread  her  virus  unrestrained  because 
relations  had  with  her  are  immoral.  Such  immorality  would  probably 
largely  disappear  or  at  least  become  minimal  instead  of  widespread 
and  flagrant  if  the  organization  of  society  made  early  marriage  possible. 
The  community  is  responsible  for  this  situation  and  equally  with  the 
individual  must  begin  the  restitution. 

In  males  "cured"  cases  often  infect  their  wives  unknowingly  because 
full  bacteriologic  investigation  was  not  done  before  discharge  from 
treatment  or  because  the  patient  refused  to  heed  advice.  Conversely, 
like  the  prostitute,  some  men  will  viciously  infect  women  although 
they  have  good  reason  to  know  that  they  are  carriers  of  the  disease. 
Both  circumstances  require  in  each  sex  suitable  instruction  preferably 
by  prophylactic  pamphlets  or  leaflets  suqji  as  most  boards  of  health, 
many  hospitals  and  clinics,  and  an  increasing  number  of  physicians  in 
their  private  practice  now  give  out.  Unsuspecting  infection  by  the 
male  arises  from  complications  in  the  glands  of  the  uretlira,  prostate, 
seminal  vesicle  and  epididymis  because  the  infectious  material  cannot 
be  secured  excepting  under  sexual  stimulation  and  ejaculation.  Social 
order  requires  limitation  of  these  accidents  by  suitable  preventive 
measures. 

In  general  gonococcal  disease  in  either  sex  and  at  all  ages  may  be 


4SS  GEXERAL  PNIXCIPLES  OF  TREATMENT 

described  as  a  deA'astatiou  of  the  sexual  organs  more  rather  than  less 
serious,  as  a  menace  to  the  reproductive  power  of  the  individual  in 
after  life  and  as  all  too  frequently  a  burden  on  the  bodily  health,  as 
exemplified  in  the  sections  on  Extragenital  Complications  of  Acute 
and  Chronic  Urethritis,  on  pages  201  and  313,  with  particular  refer- 
ence to  the  sequels  hi  the  m'inary,  circulatory  and  loconiotory  systems. 
An  oti'ender  with  such  a  long  list  of  pathological  crimes  certainly 
deserves  the  sentence  of  full  prophylactic  measures  of  all  kinds  both 
possible  and  })ractical,  and  both  personal  and  social. 

Technic— I'inal  responsibility  does  not  rest  with  medical  science 
nor  Nvith  the  medical  i)ractitioner  who  exercises  all  reasonable  known 
precautions  and  methods  of  examination,  but  does  accrue  to  the  indi- 
vidual who  more  or  less  ^■oluntarily  and  incontinently  acquired  the 
disease.  This  is  an  argument  which  the  Axriter  never  fails  to  advance 
to  a  patient  seekmg  advice  as  to  marriageability,  because  methods  of 
investigation  may  fail  to  detect  foci  of  infection  which  the  sexual  stmi- 
ulation  of  wedlock  lights  up.  Fitness  for  marriage  in  either  man  or 
woman  must  rest  on  smear  and  cultm'c  bacteriologic  tests  and  on  the 
gonococcal  complement  fixation  test,  and  the  former  must  be  obtained 
in  both  the  quiescent  and  the  stimulated  conditions. 

In  the  male  quiescent,  m*ine  should  be  retained  in  the  bladder  as  long 
as  possible  so  as  to  permit  secretion  to  accmnulate  in  the  m'cthra. 
After  four  or  five  hours'  supply  of  iu*ine,  smear  and  culture  are  taken 
from  the  urethra  with  the  sterilized  platinum  needle  after  massage  of 
the  prostate,  seminal  vesicles  and  m'cthra  combined  with  stripping  of 
the  canal  to  bring  the  products  to  the  meatus.  Urination  into  Glass  I 
brings  with  it  the  contents  of  the  canal  and  the  massage  may  be 
repeated  and  its  product  secured  by  evacuating  the  bladder  completely 
into  Glass  11.  Another  method  is  to  strip  the  m"etlu-a  for  the  smear 
and  cultm-e,  then  secm-e  Glass  I,  next  massage  the  prostate  and  vesicles 
and  take  Glass  II.  With  the  platmum  needle  slu'cds  from  the  anterior 
urethra  and  thickened  masses  of  mucus  or  pus  are  secured  for  the  cover 
glass  and  cultiue  preparations  which  should  be  several  in  nmuber  for 
the  f idlest  possible  laboratory  investigation.  In  the  male  stimulated 
efl'ort  is  to  secure  specimens  from  the  mucous  membrane  and  the 
sexual  organs.  A  sound  or  dilator  may  be  passed,  mild  h'ritating 
irrigations  employed  and  excitants  such  as  alcohol  in  the  so-called  "  beer 
test"  and  highly  seasoned  foods  may  be  employed  to  stimulate  the 
mucosa  to  more  than  usual  exudation.  The  best  test  is  that  of  securing 
semen  in  a  condom,  especially  when  the  patient  is  married  and  has 
acquired  the  disease  guiltily  and  desires  to  return  to  his  family 
tie.  It  is  an  open  question  whether  the  mtercourse  test  should  be 
recommended  for  single  men  on  moral  grounds,  but  the  question 
may  be  compromised  by  having  the  patient  wear  a  condom  at  night. 
This  procedure  soon  induces  a  seminal  emission  and  answers  the 
purpose. 

In  general  it  may  be  said  that  a  man  is  marriageable  when  he  is  free 
of  all  clmical  manifestations  of  the  disease  and  has  so  remained  for  a 


PREVENTIVE  TREATMENT  489 

considerable  space  of  time,  many  weeks  or  several  months  rather 
than  a  few  days  or  a  few  weeks  and  when  the  most  strict  laboratory 
examination  of  specimens  secured  during  repeated  quiescent  and 
stimulated  states  are  negative  and  when  the  gonococcal  fixation  test 
is  negative.  On  the  other  hand,  it  is  extremely  doubtful  whether  he  is 
marriageable  at  all  in  the  presence  of  chronic  lesions  which  gi\'e  clinical 
symptoms,  such  as  shreds  in  the  urine  and  a  morning  drop  proceeding 
from  foci  in  the  prostate,  seminal  vesicles  or  testicles.  Careful  labora- 
tory examinations  and  even  the  blood  test  may  all  be  negative.  There 
is  always  danger,  however,  that  frequency  of  intercourse  in  marriage 
may  cause  appearance  of  infection  otherwise  not  detected  and  thus 
opinion  should  be  given  with  reserve  and  caution  and  the  responsibility 
placed  with  the  individual  and  not  with  the  science  of  medicine. 

The  female  quiescent,  without  a  douche  for  at  least  twenty-four 
hours,  should  produce  smear  and  culture  specimens  from  the  secretion 
of  the  vulva,  urethra  after  expression  of  the  contents  of  Skene's  glands, 
the  vulvovaginal  glands  after  massage  and  expression  of  their  secretion, 
the  posterior  cul-de-sac  wdiere  the  cervix  drains  into  the  vagina  and  the 
cervix  uteri.  Examination  of  the  womb  and  its  annexa  by  the  bunanual 
method  for  changes  in  consistency,  mobility,  size,  tenderness  and  the 
like  with  appearance  of  discharge  at  the  close  of  the  manipulation  is 
of  definite  aid.  The  female  stimulated  is  investigated  by  pressure  on 
the  glands  of  Skene  in  the  urethra  with  a  hairpin  or  other  blunt  instru- 
ment, by  fairly  active  massage  of  the  vulvovagmal  glands,  by  mild, 
blunt  curetting  of  the  mucosa  of  the  cul-de-sac  and  cervix  and  by 
applications  of  1  or  2  per  cent,  silver  nitrate  followed  within  twenty- 
four  hours  by  the  taking  of  the  specimen.  Sexual  congress  in  woman 
is  not  to  be  recommended  for  producing  the  congestion  which  will 
bring  hidden  organisms  to  the  surface,  but  the  increased  flow  of  mucus 
just  before  and  after  menstruation  rests  on  hj^peremia  and  often  con- 
tains organisms  otherwise  not  discovered. 

In  general,  as  in  the  male,  rules  of  prophylaxis  camiot  be  too  rigid. 
Numerous  tests  must  be  made  in  the  three  general  periods  of  quiescence 
and  excitement  by  chemical  applications  and  by  menstruation.  All 
the  common  foci  of  infection  must  be  repeatedly  explored  as  just 
enumerated.  If  these  tests  are  negative  and  if  there  are  no  clinical 
signs  of  disease,  the  woman  may  be  pronounced  with  reasonable 
certainty  cured,  and  such  adverse  chance  as  ma}'  remain  is  not  the 
responsibility  of  medical  science  but  of  the  individual  if  infected  by 
immorality  or  of  her  husband  if  diseased  through  marital  infidelity.  In 
the  female,  as  in  the  male,  there  are  undoubtedl}'  foci  which  occasionally 
though  rarely  harbor  the  gonococcus  for  long  periods,  midiscoverable 
by  exammation  and  only  micoverable  by  the  regular  sexual  stimula- 
tion of  married  life.  In  particidar  in  the  female  also,  if  there  are  clinical 
signs  of  disease  which  defy  treatment,  such  as  persistence  of  leucorrhea 
and  the  meatal  urethi-al  drop,  pus  in  the  ^1dvo^'aginal  glands  and  cul- 
de-sac  and  mucopm-ulent  discharge  from  the  cervix  and  inflammatory 
fixation  and  other  changes  in  the  womb  and  its  amiexa  after  a  known 


400  GEXERM.  rh'IXriri.FS  OF  rREAr}fENT 

i^onococcal  iiitVH'tion.tlu'u  uri-at  caution  nuist  l)e  excrcisiHl  in tlie  decision 
of  marriageability  although  all  tests  may  be  in  themselves  negative. 

Gonococcal  complement  fixation  test  is  of  great  value  in  the  deter- 
mination of  the  presence  of  foci  causing  absorption  but  clinically 
l)crhai)s  undiscovereil  or  difhcult  of  api)roach  for  the  purely  baeterio- 
logic  diagnosis.  Olniously,  it  a])i)lies  ecjually  \vell  in  both  sexes  and 
is  looked  upon  as  more  reliable  for  prophylaxis  than  is  the  syphilitic 
complement  fixation  test — called  the  Wassermann  reaction.  It  pos- 
sesses great  technical  difficulties  in  the  culture  of  the  fifteen  or  more 
strains  of  the  gt)nococcus  for  the  ])rcj)aration  of  the  antigen  and  nuist 
therefore  be  ])erfonnc(l  by  a  very  competent  laboratory. 

ABORTIVE  TREATMENT. 

Purposes. — The  aim  of  abortive  treatment  is  to  o\ercome  the  infec- 
tion during  the  earliest  periods  when  the  subjective  s,Miiptoms  are 
minimal  and  perceived  only  by  the  most  intelligent  subjects.  This 
means  that  the  case  must  be  reached  before  the  jjeriod  of  exfoliation 
is  past  and  before  the  stage  of  penetration  is  established  with  the  gono- 
coccus  deep  in  the  epithelial  layers.  The  lesions  must  be  at  the  meatus 
and  its  annexa  and  not  extended  far  back  in  the  canal. 

Selection  of  Case. — It  follows,  therefore,  that  the  patient  must  be 
seen  very  early,  while  the  discharge  is  scanty  and  serous,  mucous, 
seromucous,  as  a  thin  watery  moistiu-e  or  a  slight  stickiness  according 
to  the  proportion  the  mucus  or  the  serimi  predominates.  To  the 
naked  eye  the  fluid  is  clear  and  to  the  microscope  it  contains  epithelia, 
pus,  gonococci,  without  or  with  other  organisms,  all  in  moderate 
ciuantities.  In  short,  the  patient  should  be  seen  during  the  first  twelve 
hours  after  coitus.  Any  time  longer  than  twenty-four  hours  directly 
militates  against  success. 

Methods. — The  means  of  abortive  treatment  are  those  of  application, 
irrigation,  injection,  instillation  by  the  patient  and  instillation  with 
retention  (Ballenger's  method).  The  chief  point  is  to  prefer  the  gen- 
tlest method  possible  with  nonirritating  solutions  and  with  rather 
frequent  attention  and  long  retention.  For  these  reasons  the  author 
prefers  the  syringe-and-catheter  irrigation  with  1  in  8000  to  1  in  4000 
solution  of  potassiimi  permanganate  two  or  three  times  daily,  hot 
within  comfort  and  imder  pressure  without  pain  or  distress  and  applied 
only  to  the  anterior  urethra  after  urination.  In  the  intervals  between 
these  irrigations  the  patient  instils  with  a  medicine  dropper  argyrol 
solution,  3  to  10  per  cent.,  into  the  meatus  and  fossa  while  the  penis  is 
hekl  in  the  vertical  jiosition.  By  capillary  attraction  between  the 
surfaces  of  the  collai)sed  walls  of  the  urethra  the  fluid  will  travel  back 
as  far  as  necessary.  The  patient  retains  these  drops  for  at  least  ten 
minutes  and  may  furthermore  soak  his  penis  in  hot  mild  antiseptics, 
such  as  the  foregoing  solutions  of  potassiimi  permanganate  and  argyrol. 
Hand  injections  are  ajjt  to  be  o\'erdone  by  the  ignorant  and  should 
be  reserxed  for  the  intelligent  class.    These  details  are  continued  from 


VALLIATIVE  TREATMENT  491. 

three  to  five  days  with  frequent  bacterioloKif;  investigation  to  judge 
of  their  eff'eets  on  the  organisms  and  ('i)ithelia. 

Instillation  and  Retention  Method. — ''i  his  is  the  procedure  of  Ballenger 
as  noted  in  the  section  on  the  details  of  abortive  treatment  of 
acute  urethritis  on  page  49.  Its  principles  are  very  early  rliagnosis 
and  the  instillation  of  not  more  than  30  minims  of  argyrol  solution  5 
per  cent,  and  then  sealing  the  same  into  the  urethra  with  collodion 
and  cotton  for  about  five  hours  and  repeating  the  process  each  day  for 
several  days  until  the  gonococci  disappear.  Ballenger  is  positive  of 
his  records  and  enthusiastic  about  his  results.  The  author  has  had  no 
experience  with  the  method  because  it  is  so  difficult  to  have  dispensary 
patients  call  at  the  proper  period  for  its  successful  application.  In 
theory,  however,  and  on  the  basis  of  Ballenger's  reports  the  technic 
makes  a  strong  appeal  for  itself. 

The  full  details  of  all  these  abortive  methods  will  be  found  in  the 
Chapter  on  Acute  Urethritis  in  the  sections  on  treatment. 

PALLIATIVE  TREATMENT. 

Purpose. — Palliation  is  aimed  to  relieve  symptoms  rather  than  really 
cure  lesions.  '  In  gonococcal  disease  the  sjrmptoms  follow  so  rapidly 
upon  each  other  and  cause  so  much  distress  that  comfort  must  be 
secured  definitely.  The  predominant  symptoms  are  due  to  conges- 
tion, irritation,  discharge  and  distiubed  function  —  all  due  to  the 
activity  of  infecting  organism.  The  destruction  of  the  gonococcus  is 
in  a  certain  sense  the  one  true  curative  measure  and  will  relieve  all  the 
foregoing  conditions;  but  other  treatments  are  necessary  in  order  to 
palliate  the  suffering  while  the  invariably  slow  process  of  this  destruc- 
tion is  in  development. 

Methods. — The  congestion  is  relieved  by  sedatives  by  internal  admin- 
istration and  decongestants  locally  applied.  Among  the  best  are  the 
thermic  measures,  cold  in  the  ice-bag  or  coil  and  heat  in  the  bag  or 
sitz  bath  and  heliotherapy,  which  are  best  in  the  acute  period  but 
available  in  the  clu'onic  stages  especially  with  exacerbations.  Electro- 
therapy by  selected  method  is  of  use  in  the  chronic  period.  Irritation 
corresponds  with  the  congestion  and  is  indirectly  benefited  by  the 
same  measures.  The  sedatives  by  mouth  are  especially  good,  chiefly  for 
the  m'inary  and  sexual  disturbance.  The  urine  is  diluted  and  neutral- 
ized by  the  drinking  of  plain  or  alkaline  water  without  inducing  undue 
frequency  or  urgency.  The  sexual  irritation  is  primarily  prevented  by 
avoiding  all  direct  and  indhect  sexual  stimulation,  and  secondarily 
corrected  by  the  further  administration  of  sedatives  and  by  regular 
evacuation  of  the  bladder. 

The  discharge  is  the  chief  sign  of  the  disease  and  its  true  palliation 
is  closely  identified  with  its  ciu-e  because  as  the  discharge  disappears 
the  infection  decreases  and  the  germ  vanishes.  On  the  other  hand,  the 
severity  of  the  discharge  may  be  diminished  by  reducmg  the  congestion 
and  the  u'ritation  and  by  the  rest  and  quiet  of  good  management. 


492  GEXERAL  PRIXCIPLES  OF  TREATMENT 

Perhaps  above  all  other  details  judicious  treatment  which  does  not 
increase  the  disciiarge  is  to  be  remembered.  Disturbed  function 
embraces  th6  frequency  and  pain  of  m'ination  antl  the  repetition  and 
excitement  of  sexual  reHexes.  All  are  interwoven  with  the  other 
symptoms  and  are  therefore  soothed  and  palliated  by  the  measures 
alreadx'  alluded  to,  notal)ly  by  sedatives  systemically  administered 
and  by  the  local  influence  of  hydrotherapy,  the  relief  of  the  infection 
and  the  neutralization  of  the  urine. 

CURATIVE  TREATMENT. 

Purposes. — -V  cure  cannot  be  established  unless  the  gonococcus  is 
destroyed  as  the  primary  factor  in  the  disease  and  unless  the  mucosa 
is  reasonably  restored  and  unless  the  full  function  of  all  the  tissues  and 
organs  attacked  is  virtually  revived.  The  former  aim  is  rather  easily 
attained,  while  the  latter  is  often  impossible  in  the  full  sense  because 
the  mucosa  is  so  badly  damaged.  As  long  as  the  gonococcus  survives, 
the  ease  is  not  ciu-ed  and  relapse  is  possible  and  complications  somewhat 
likely  and  most  important  infection  of  the  opposite  sex  innocently  in 
wedlock  is  a  certainty.  The  mucosa  is  often  restored  in  many  cases 
so  far  as  the  exfoliation  and  much  of  the  penetration  are  concerned. 
Scar  tissue  formation  in  the  form  of  strictnre  and  thickenings,  however, 
cannot  be  removed.  The  function  is  renewed  in  the  little  glands  of 
the  mucosa  and  in  the  annexa  of  the  m'ethra.  jNIucous  crypts  are 
stinudated  to  healthy  secretion  in  both  sexes  and  the  prostate,  testes, 
vasa  deferentia,  and  seminal  vesicles  in  the  male  should  regain  their 
physiology  and  in  the  female  the  lining  of  the  uterus  should  cast  off 
the  catarrhal  aftereffects,  the  tubes  become  patent  and  ovulation  occur 
normally — all  as  fully  discussed  under  the  treatment  of  the  various 
lesions  of  these  organs  in  the  male  and  female. 

Methods. — The  cure  is  reached  in  general  by  one  of  two  methods 
—expectant  or  radical,  commonly  called  irrigation — or  by  both  com- 
bined in  judicious  proportion,  as  perhaps  the  best  method. 

Expectant  Method. — The  expectant  plan  makes  great  study  of  the 
periods  and  symptoms  of  the  disease  and  rests  on  correct  diagnosis 
of  lesions  no  matter  whether  acute  or  clironic.  In  a  certain  sense  it 
demands  management,  diet,  rest  and  internal  medication  as  systemic 
means  for  their  local  effects  until  the  acute  period  is  over.  Then  the 
local  means  for  local  effects  are  employed  chiefly  as  hand  injections 
by  the  patient  and  s;>Tinge-and-catheter  irrigations  by  the  surgeon. 
i\Iild  strengths  of  solution,  frequent  but  gentle  applications,  and  long 
retention  of  fluids  are  the  ground  work.  Physical  measures,  if  applied 
*at  all  during  the  acute  period,  are  comprised  only  in  hydrotherapy 
as  heat  or  cold  according  to  comfort  and  result  or  in  heliotherapy  of 
mild  degree  and  long  duration.  jNIassage  and  electrotherapy  are 
interdicted.  jMedicinal  measures  must  not  be  distiu-bing  to  the 
patient's  local  or  systemic  economy.  During  chronic  periods  the 
conditions  change.     Any  case  which  has  lasted  from  tlu-ee  to  four 


CURATIVE  TREATMENT  493 

months  is  of  essentially  elironit;  ])atlio<i;enesis.  The  diagnosis  must  be 
correet  and  is  of  prime  importance.  The  history  reveals  the  duration 
and  frequency  of  antecedent  attacks.  Symptoms  indicate  the  activity 
and  relapses  of  the  disease,  while  physical  examination  detects  the 
chief  lesions  and  verifies  them  with  the  urethroscoi)c,  cystoscope  and 
the  laboratory  specimens,  which  finally  reveal  the  infectiousness. 
Response  by  the  patient  subjectively  and  objectively  is  the  best  guide 
of  method  and  manner  and  frequency  of  treatment. 

As  a  rule,  no  two  methods  of  treatment  should  be  combined  at  one 
sitting;  for  example,  massage  of  the  prostate  or  seminal  vesicles  should 
not  be  combined  with  a  passage  of  a  sound  because  the  latter  is  also  a 
form  of  massage.  An  exception  is  the  use  of  Bangs's  urethral  sound 
in  associating  instillation  with  dilatation  and  the  employment  of  the 
author's  irrigating  sounds  in  correlating  dilatation  with  lavage  of  the 
bladder  and  retrojection  of  the  urethra.  These  exceptions  hold  because 
one  passage  accomplishes  two  things  with  the  instrument.  The 
medicines  emploj^ed  are  essentially  mild  in  such  procedures. 

All  overstimulation  is  avoided  by  any  means  whatever — digital  or 
instrumental,  thermal  or  chemical,  physical  or  electrical  and  finally 
physiological,  directly  or  indirectly,  because  any  such  stimulation 
has  a  direct  tendency  to  add  to  the  inflammation.  The  general  fre- 
quency of  treatment,  if  excessive,  is  another  means  of  increasing  the 
inflammation.  In  general,  whenever  the  symptoms  increase  the  fre- 
quency is  either  too  little  or  too  much — a  question  which  must  be 
decided  by  the  course  of  the  disease  after  a  change  in  either  direction. 
Undue  activity  is  usually  a  mistake  by  the  patient  in  the  use  of  his 
hand  injection. 

The  absence  of  progress  indicates  a  change  in  the  treatment  or  dis- 
obedience by  the  patient  to  advice  or  orders.  The  urethral  treatment 
may  be  wrong  or  too  strong,  the  visits  too  frequent  and  instrumental 
applications  too  irritating.  Caution  cannot  be  too  great  about  any 
reaction  to  sounds  "o  that  flexible  instruments  are  much  to  be  pre- 
ferred to  steel  instruments  even  in  the  hands  of  the  expert  and  espe- 
cially in  the  hands  of  the  general  practitioner.  The  patient  may  be 
disobedient  in  indulging  in  normal  or  perverted  intercourse  or  in 
irregularity  in  diet,  drink  or  habits.  The  author  had  a  case  whose 
stationary  condition  rested  solely  on  frequent  sexual  per^'ersions,  which 
he  thought  were  not  harmful,  although  he  abstained  from  normal 
coitus,  which  he  recognized  as  harmful  because  forbidden.  He  rapidly 
recovered  when  the  perversions  ab  ore  were  abandoned. 

Irrigation  Metlicd. — This  method  is  sometimes  called  the  radical 
plan  because  it  has  more  respect  for  the  immediate  destruction  of  the 
infecting  organism  as  such  than  it  has  for  the  periods  and  symptoms  of 
the  disease  as  guides  to  ths  details  of  treatment.  Its  minutiae  are  fully 
covered  in  the  paragraphs  dealing  with  this  method  in  the  treatment 
with  each,  lesion  of  the  gonococcus  as  it  arises.  The  author  believes 
that  the  good  points  of  the  irrigation  method  in^'olved  in  the  gentleness 
qf  the  syringe-and-catheter  procedure  when  combined  with  the  mstincts 


494  GENERAL  I'h'l XCIPLES  OF  TREATMENT 

of  the  expectant  nu'tliod  in  ivspocting  tho  stages  of  the  (Hsease  are  jirob- 
ably  the  best  \)\iu\  of  treating  acute  uretln-itis.  The  term  combined 
nu>tliod  might  b{>  appHed  to  this  dcx'clopnient  of  tr(>atment. 

SYMPTOMATIC  TREATMENT. 

•  Purposes. — Symptomatic  measures  are  Hke  palhiition  and  synony- 
mous witli  it.  The  indications  ofi'ered  by  the  patient's  sutl'criuus  are 
sufli<-iently  discussed  vmder  paUiative  treatment. 

Methods.—  The  ])atient's  story  shouhl  be  carefully  elicited  and  the 
sui)jccti\e  local  symptoms  and  subjective  systemic  syndrome  must  be 
known.  A  careful  objecti^'e  examination  verifies  these  leads  for  the 
local  and  systemic  objective  corroboration.  Xo  method  of  examination 
can  be  omitted.  The  older  methods  of  physical  investigation  arc  al\va\s 
emi)loyed — ins])ection,  palpation,  mensuration,  percussion  and  aus- 
cultation. These  must  be  augmented  by  special  examination,  such  as 
the  laboratory  analyses  of  urine,  semen  and  discharge,  bacteriology 
in  smear  and  culture  and  hematology  for  bacteremia  and  the  c()m])le- 
ment  fixation  tests.  Instrumental  and  digital  investigation,  are  ]K)ssibIe, 
and  are  emjjloyed  for  the  rectum,  urethra,  bladder,  ureters  and  kidne\'s, 
including  urethroscopy  and  cystoscopy  and  functional  tests  of  the 
kidneys.  When  the  pathogenesis  of  the  symptom  is  determined  then 
the  method  of  treatment  is  selected,  on  the  principles  just  discussed, 
and  so  continued. 

INDICATIONS  OF  TREATMENT. 

Varieties. — Tliere  are  two  aspects  of  this  subject:  the  j^athologic  and 
the  symptomatic.  The  symptomatic  indications  are  fully  s\nonymous 
with  s.MTiptomatic  treatment  as  already  discussed  in  the  preceding 
paragraph. 

Pathologic  Indications. — Due  regard  must  be  had  for  the  essence  of 
the  lesions,  as  j)roduced  by  a  germ  active,  penetrating  and  extending. 
Such  regard  determines  a^'oidance  of  any  treatment  which  will  over- 
stimulate,  irritate  or  damage  the  mucosa  and  thus  increase  the  dis- 
ease in  extent  and  depth  by  causing  a  traumatic  inflammation,  either 
physical,  chemical  or  thermal.  The  tissues  in\'olve(l  should  be  remem- 
bered as  finally  the  mucosa  in  all  its  layers.  The  ej)ithclia  of  the  surface 
of  the  mucosa  and  its  glandules  are  primarily  compromised,  and  then 
secondarily  the  submucosa  with  the  underlying  connective  tissue.  The. 
same  law  of  invasion  and  advance  is  noticed  in  the  organs  attacked. 
The  mucosa  at  first  of  the  ducts  and  then  of  the  acini  and  finally  of 
the  stroma  and  the  parench^'ma  in  small  or  large  zones  suffers.  The 
temporary  lesions  are  chiefly  exfoliation,  which  may  be  fully  restored, 
and  small  round-cell  infiltration,  which  may  be  entirely  absorbed. 
Hence  no  treatment  nmst  excite  undue  shedding  of  the  e])ithelia  or 
chemical  inflannnation  of  the  surface  and  depths  of  the  lining.  The 
permanent  lesions  represent  replacement  of  normal  l)y  substitution 


MANAGEMENT  495 

tissue.  Columnar  epithelia  fi;ivcs  way  to  squamous  cells,  soft  fibro- 
elastic  tissue  is  changed  into  dense  fibrous  tissue  or  that  which  is  much 
less  elastic.  Both  processes  an;  iiivit(;d  and  increased  by  harsh  treatment 
and,  in  fact,  such  treatment  will,  if  (ixtrenu;,  induce  them  in  perfectly 
normal  mucosa.  The  associated  lesions,  if  gonococcal,  follow  the  same 
pathogenesis.  The  most  common  associated  lesion  is,  of  course,  the 
urethritis  from  which  other  important  lesions  have  arisen.  The  same 
statements  concerning  co7Tipli(;ating  lesions  apply  with  equal  force. 
The  gonococcus  and  its  allies  constitute  the  bacteriology  of  each  case 
and  the  latter  must  always  be  in  mind  in  the  matter  of  orrhodiagnosis 
and  orrhotherapy. 

MANAGEMENT. 

Definition, — The  general  care  of  the  patient,  not  including  the  adminis- 
tration of  drugs,  constitutes  management. 

Importance. — The  importance  of  good  management  almost  equals 
that  of  the  proper  selection  and  administration  of  both  internal  and 
local  measures  and  is  in  fact  the  groundwork  on  which  reposes  the 
absence  of  errors  chiefly  by  the  patient  and  sometimes  by  the  doctor, 
which  add  to  the  disease  and  delay  recovery.  Under  this  heading  are 
necessarily  included  the  general  subjects  of  hygiene,  rest,  diet,  drink, 
nursing,  dressing. 

Hygiene. — Gould^  defines  this  term  as  follows:  "The  science  that 
treats  of  the  laws  of  health  in  its  broadest  sense."  Employing  this 
term  in  a  similarly  free  sense  the  author  means  all  those  elements 
of  general  and  local  care  which  avoid  factors  which  in  any  way 
endanger  progress  of  the  disease,  limit  the  effects  of  treatment  and 
invite  the  inoculation  of  others.  In  part,  therefore,  hygiene  of  gono- 
coccal disease  is  embraced  under  management  and  again  under  pro- 
phylaxis, personal  and  social.  It  likewise  embraces  each  of  the  other 
elements  named  at  the  close  of  the  section  on  Management.  It  may  be 
accepted,  therefore,  to  mean  the  general  common  sense  essential  in  the 
respect  by  the  patient  for  his  bodily  processes  in  any  disease. 

Rest. — Relief  of  the  body  of  weariness,  which  in  the  stress  of  every- 
day life  somewhat  invites  sickness  and  indirectly  increases  it,  is  a  very 
important  element  in  gonococcal  disease  when  the  patient  is  not  doing 
well.  In  all  the  armies  and  navies  of  the  world  the  enlisted  men,  when 
infected,  are  immediately  put  to  bed  for  at  least  three  reasons:  (1)  the 
repose  limits  the  extension  of  the  disease  and  often  prevents  compli- 
cations; (2)  the  patient  is  fully  under  the  control  of  the  medical  officer 
and  under  the  hourly  care  of  the  nurse ;  (3)  the  patient  learns  a  greater 
respect  for  his  affliction  and  is  decidedly  constrained  in  his  likeliliood 
to  infect  others.  Every  urologist  has  had  familiar  examples  of  cases 
who  did  badly  while  ambulant  but  extremely  well  as  soon  as  put  to 
bed.  Bodily  rest  has  therefore  at  least  the  foregoing  advantages  and 
it  is  unfortunate  that  social  conditions  prevent  this  treatment  in  the 

1  Illustrated  Dictionary  of  Medicine,  Biology  and  Allied  Sciences,  1902. 


496  GENERAL  PRINCIPLES  OF  TREATMENT 

majority  of  cases.  Sexual  rest  is  a  tletail  which  demaiuls  more  atten- 
tion in  a  certain  sense  because  every  intelligent  patient  can  carry  it 
out.  The  victim  of  gonococcal  infection  may  expect  indefinite  amounts 
of  trouble  if  he  is  ever  exciting  his  disease  by  exciting  his  sexual  passion, 
indirectly  by  the  comjianionship  of  women  which  may  be  aAoided  or 
by  the  fondling  of  liis  financec  which  may  be  largely  limited  if  not 
totally  stopped,  or  directly  iiy  intercourse  when  he  thinks  his  disease  is 
well  but  before  the  surgeon  after  the  most  careful  analysis,  as  described 
under  the  headings  of  Diagnosis  and  Cure  of  each  lesion  in  turn,  has 
declared  it  well.  In  the  female,  as  in  the  male,  absence  of  sexual  rest 
largely  defeats  treatment,  as  is  seen  in  the  prostitute  who  continues 
her  initial  infection  by  her  life  and  also  incurs  the  risk  of  reinfection. 

Diet.  -Full  details  of  this  subject  cannot  be  drawn  and  the  reader 
is  referred  to  works  on  the  subject.  In  general,  the  fever  diet  employed 
in  most  hospitals  consisting  of  fluids  is  available.  Milk  and  milk 
products  alone  or  mixed  with  Vichy  or  carbonic  water,  light  soups  and 
broths  with  little  seasoning,  breadstuH's,  fish  and  mild  fruits  are  all 
available  as  the  case  begins  to  improve.  Later,  when  the  acute  symp- 
toms are  past,  the  easily  digested  vegetables  followed  by  meats  with 
chicken  first  are  all  added.  In  general,  that  diet  is  avoided  which  tends 
to  increase  crystals  in  the  lu'ine.  Meat  usually  develops  uric  acid  and 
urates,  while  oxalates  may  be  produced  by  tomatoes,  asparagus,  rhu- 
barb and  strawberries.  If  the  patient  uses  a  diet  which  he  digests 
freely  without  constipation  or  urinary  disturbance  in  health,  he  may 
employ  the  same  diet  after  the  severe  period  of  the  gonococcal  disease 
has  passed. 

Drinks. — ^Mineral  waters,  especially  of  the  alkaline  and  mildly 
diuretic  tvpes,  are  best.  Even  plain  water  with  a  pin^jh  of  bicarbonate 
of  soda  (10  to  15  grains)  is  a  good  substitute.  The  fluid  of  the  diet 
must  not  be  forgotten  in  determining  the  quantity  of  AA'ater  to  be  taken, 
which  must  not  be  so  great  as  to  increase  the  blood-pressure  or  to  con- 
gest the  bladder  and  prostate  by  the  bulk  of  fluid  excreted.  The  object 
is  only  such  frequency  of  urination  as  to  dilute  the  acidity  if  not 
chemically  neutralize  it  and  thus  decrease  irritation  of  the  inflamed 
mucosa  and  so  to  flush  the  pus  from  the  urethra  under  Nature's  own 
pressure  and  thus  to  help  her  In  the  effort  to  cast  off  the  disease  by 
the  pus. 

Alcoholijs  in  all  forms  are  forbidden,  because  alcohol  in  the  urine 
violently  inflames  the  disease  exactly  as  it  pains  and  burns  a  raw  surface. 
The  a^■erage  drinker  of  alcohol  takes  considerably  more  than  his  body 
will  consume  as  food  and  cast  from  itself  in  altered  form.  He  therefore 
has  a  certain  quantity  of  unaltered  alcohol  in  his  blood  and  urine.  It 
is  this  percentage  which  cause  ^  the  difficulty. 

Tobacco.^It  is  doubtful  whether  the  use  of  tobacco  except  in  great 
excess  has  any  influence  on  the  infection.  Such  exces3,  however,  by 
deprec  iating  resistance  may  add  to  the  severity  of  the  attack. 

Nursing. — Unless  the  patient  is  put  to  bed,  nursing  during  the  acute 
period  is  not  a  factor  except  within  the  limit  of  the  patient's  own  care 


PHYSICAL  MEASURES  497 

of  himself.  The  severe  complications,  however,  such  as  those  of  the 
prostate,  testicles,  bladder,  kidneys  or  extragenital  organs,  especially 
the  eye,  require  the  most  expert  nurses.  None  but  those  trained  in  this 
service  should  be  employed.  Manifestly  the  male  nurse  fulfils  one 
of  his  best  fields  in  this  regard  for  the  male  'ubject.  Female  nurses 
may  be  trained  to  do  it  very  well  but  have  the  difficulty  of  not  infre- 
quently offering  subconsciously  sexual  stimulation. 

Dressings. — The  form  of  dressing  is  fully  discussed  in  the  paragraph 
of  acute  inflammation  in  both  sexes.  The  cotton  plug  which  imprisons 
the  discharge  within  the  urethra  of  the  male  or  within  the  urethra  and 
the  vagina  of  the  female  is  folly,  because  it  checks  Nature's  first  effort 
at  cure,  which  is  the  discharge.  The  apron  dressing  for  the  male  and 
the  so-called  gonorrheal  bag,  loosely  fitted,  are  the  only  wise  dressings, 
and  similarly  a  soft  vulvar  pad  or  towel  loosely  applied  in  the  female. 
The  surgeon  does  not  block  up  the  discharging  sinus  of  a  healing  wound, 
but  encourages  it  to  drain  itself  clean  from  hour  to  hour.  The  urologist 
should  follow  the  same  rule  and  should  not  block  up  the  urethra  in  the 
male  or  female  which  in  a  broad  sense  are  sinuses  when  infected  or 
put  a  plug  into  the  vagina  which  in  a  similar  sense  is  a  wound  cavity 
when  infected.  The  drainage  of  these  parts  free  of  gonococcal  pus 
should  not  be  hindered  by  faulty  dressings  any  more  than  the  develop- 
ment of  the  pus  should  be  stimulated  by  erroneous  treatment. 

Further  details  concerning  management  in  each  gonococcal  affection 
are  mentioned  in  the  paragraphs  on  its  treatment. 

PHYSICAL  MEASURES. 

Varieties. — The  four  common  physical  forms  of  treatment  are  avail- 
able in  the  proper  cases  and  stages  of  gonococcal  disease  and  are 
massage,  hydrotherapy,  local  or  general,  heliotherapy  and  electro- 
therapy, local  or  general. 

Purposes. — The  fact  is  that  many  of  the  other  forms  of  treatment 
affect  only  the  surface  of  the  mucous  membrane  where  it  is  reached 
by  application,  instillation,  injection,  irrigation  or  instrumentation. 
This  is  the  reason  that  physical  measures  which  through  their  profound 
influence  on  the  circulation  of  the  blood,  on  the  secretion  of  glandular 
elements  and  on  an  organ  more  or  less  as  a  whole,  become  of  special 
value  when  the  disease  has  extended  beyond  the  surface  of  the  mucosa 
and  is  no  longer  benefited  by  the  other  steps.  Manifestly  these  physical 
measures  are  advisable  in  the  late  subacute  and  chronic  stages  and  are 
forbidden  in  the  acute  periods. 

Massage. — •Forms. — ^^lassage  is  employed  in  lu-ological  work  either 
with  the  finger  or  with  an  instrument,  either  attached  to  the  finger  or 
held  in  the  hand.  It  is  almost  needless  to  say  that  digital  massage  alone 
is  advisable  because  it  permits  the  finger  first  to  detect  the  chief  point 
of  the  disease  requii'ing  stimulation  and  second  to  observe  the  effect 
of  the  treatment.  Moreover,  it  brings  the  normally  elastic  tissue  of  the 
finger  into  contact  with  a  diseased  and  perhaps  badly  damaged  gland 
32 


498  GENERAL  PRINCIPLES  OF  TREATMENT 

SO  that  the  perception  of  the  surgeon  matches  that  of  the  patient  in 
avoiding  violence  and  secondary  injury.  On  the  other  hand,  an  instru- 
ment attached  to  the  finger  or  held  in  the  hand  for  manipulation,  by 
finger  or  hand,  or  one  electrically  driven,  is  bereft  of  all  these  advantages 
and  should  never  be  used. 

Purposes.^ — To  stinuilate  the  circulation  of  the  blood  in  subacute 
and  chronic  inllainniation  is  the  chief  aim  of  massage  so  that  healing 
will  be  accom})lished  as  rapidly  as  possible.  Equally  important  is  the 
evacuation  of  unhealtliy  retained  secretion  or  pus-pockets  and  sinuses. 

Selection  of  Case. — From  the  foregoing  facts  it  follows  that  the 
glandular  in^■olvenK'nts  or  complications,  especially  those  in  the  glands 
of  Cowper,  the  prostate  and  the  seminal  vesicles  offer  the  best  field  for 
this  treatment.  Only  the  late  subacute  and  the  chronic  periods  are 
those  in  which  the  massage  should  be  employed.  If  there  is  obstruc- 
tion of  the  ducts  of  the  glands  of  Cowper  or  the  seminal  vesicles  so 
that  a  cyst  or  abscess  is  present,  massage  should  be  attempted  only 
with  caution  and  immediately  abandoned  in  case  of  failure  of  prompt 
evacuation  of  the  accumulation,  otherwise  persistence  in  this  treat- 
ment will  extend  the  infection  to  outlying  connective  tissue,  as  a  new 
complication. 

Technic. — Tlie  method  of  performing  massage  with  reference  to  its 
special  indications  is  found  in  the  paragraphs  on  the  treatment  of  each 
lesion  to  which  it  may  be  applied  in  the  Chapters  on  Chronic  Urethritis 
and  on  the  Complications  of  Urethritis. 

Hydrotherapy.— Varieties.^Water  may  be  applied  in  the  treatment 
of  gonococcal  disease  as  a  local  and  as  a  general  measure.  Its  effect  is 
really  thermal,  through  heat  and  cold,  with  their  influence  on  the 
circulation. 

Purposes. — Changes  in  the  circulation  during  the  inflammation  are 
the  amis  of  hydrotherapy  in  the  strict  sense,  although  mechanical 
removal  of  exudate  may  also  be  part  of  this  subject  through  irriga- 
tions and  injections.  Unlike  massage  and  electrotherapy,  hot  or  cold 
water  may  be  used  during  the  acute  as  well  as  the  chronic  period. 
Thus  the  congestion  and  discharge  of  the  early  days  are  benefited 
usually  by  cold  and  often  by  heat  and  the  indolence  of  the  later  stages 
is  removed  usually  by  heat. 

Selection  of  Case. — The  question  is  chiefly  the  comfort  of  the  patient 
and  the  results  of  the  method.  Some  individuals  do  better  imder  cold 
applications  while  still  others  are  relieved  by  heat.  As  a  rule,  cold  is 
best  in  the  acute  period  when  the  forced  circulation  of  the  early  inflam- 
mation needs  quieting.  The  later  conditions  call  for  heat  in  order  to 
draw  blood  into  the  sluggish  vessels  of  chronic  inflammation.  Each 
patient  is,  however,  a  law  to  himself. 

In  the  local  application  are  considered  irrigations  of  the  prepuce, 
urethra,  bladder  and  rectum  in  the  male  and  the  vagina  also  in  the 
female.  Penile  baths  must  be  included,  likcAvise  double-current  rectal 
tubes  and  the  psychrophore.  The  sitting  bath  is  a  powerful  decon- 
gestant when  properly  taken.    A  special  tub  for  this  purpose  is  con- 


PHYSICAL  MEASURES  499 

venient  but  not  essential,  because  the  patient  may  draw  ten  or  twelve 
inches  of  very  hot  water  in  his  tub  and  sit  therein  with  his  lower 
extremities  extended.  '\\\v  water  should  make  the  skin  y('(\  with  h(;at, 
the  bath  should  continue  for  from  twenty  to  thirty  minutes  and  the 
patient  immediately  returns  to  bed.  Such  a  bath  draws  the  blood 
directly  away  from  infected  internal  organ  in  both  sexes.  In  the 
general  applications  are  included  various  medicinal  baths  and  Turkish 
or  Russian  baths  for  their  eliminative  and  tonic  efl'ccts.  They  are 
available  for  the  chronic  cases  with  absorption  as  typified  by  any 
systemic  complication  and  notably  arthritis.  If  not  of  definitely  good 
result  they  had  best  be  discontinued. 

Technic— The  special  methods  of  applying  the  irrigations,  the  local 
baths  and  the  general  baths  are  either  described  in  the  paragraphs 
on  the  treatment  of  the  lesions  appropriate  for  them  or  are  so  familiar 
as  to  need  no  comment  here. 

Heliotherapy. — Definition. — The  application  of  light  to  disease  is 
known  as  heliotherapy  and  with  the  modern  means  of  the  electrical 
development  of  light,  both  incandescent  and  arc,  is  efficient  and 
serviceable. 

Varieties. — Incandescent,  arc,  white  and  colored,  are  the  usual 
varieties  and  the  most  convenient  form  for  the  urologist  is  the  so-called 
therapeutic  lamp.  It  consists  briefly  of  a  deep  parabolic  reflector 
completely  covering  and  protecting  a  50-candlepower  lamp,  a  handle 
and  the  necessary  cable  and  connector. 

Action. — ^The  intensity  of  the  light  is  thermal,  actinic  and  biochemical. 
The  thermal  influence  is  reached  by  applying  the  light  until  the  skin 
is  very  red,  exactly  as  in  hydrotherapy.  Actinic  energy  probably 
rests  in  the  ultraviolet  rays,  and  biochemistry  is  probably  both  the 
heat  and  the  actinic  action  combined.  The  local  temperatiu-e  is  raised, 
and  resistance  to  the  organisms  increased  and  a  profound  influence 
developed  on  absorption  and  resorption.  The  circulation  of  the  skin 
and  subcutaneous  tissue  is  excited,  deep  organs  are  decongested  as  in 
hydrotherapy  with  greater  convenience  of  application.  Heliotherapy 
is  available  in  all  acute  lesions  of  the  deep  organs  and  in  any  chronic 
cases  with  a  tendency  to  exacerbation. 

Selection  of  Case. — Heliotherapy  is  advisable  wherever  the  deep 
organ-s  are  infected  and  will  be  benefited  by  the  application  of  heat, 
as  in  the  complications  of  prostatitis,  seminal  vesiculitis,  cowperitis, 
salpingitis  and  oophoritis;  deeply  seated  lesions  are  benefited  by  the 
decongestion  and  superficial  lesions  by  actinic  and  biochemical  action. 
In  short,  it  is  available  wherever  hydrotherapy  is. 

Technic— The  therapeutic  lamp  and  the  details  of  its  application 
are  fully  discussed  in  the  paragraphs  on  treatment  of  each  lesion  as  it 
arises  in  the  Chapter  on  Complications  of  Acute  Urethritis. 

Electrotherapy. — Status. — This  contribution  is  not  a  brief  in  behalf 
of  or  an  apology  for  electrotherapy.  Adverse  critics  obviously  either 
have  no  equipment  at  all  or  one  that  is  deficient.  They  therefore  have 
not  had  the  experience  which  makes  their  opmion  reliable  or  final. 


500  GENERAL  PRINCIPLES  OF  TREATMENT 

It  is  a  poor  argument  to  say  that  other  methods  w  ill  do  as  well  or  as 
much.  It  is  our  function  to  be  skilled  in  all  methods  available,  because 
in  such  infections  of  the  nmeosa  as  the  gonococcal,  in  many  cases  the 
wider  the  variety  and  the  greater  the  graduations  of  treatment  the 
better  the  results.  Electrotherapy  succeeds  where  other  methods  fail; 
its  graduations  are  exact,  its  idiosyncrasies  are  imknown  and  there 
are  no  unfa\orable  reactions  if  the  form  and  intensity  of  the  current, 
the  duration  and  the  freciuency  of  treatments  and  the  aftercare  of  the 
patient  are  all  correctly  selected  and  carried  out.  There  must  be  no 
error  in  the  exact  diagnosis  of  the  disease.  It  is  peculiar  that  so  many 
other  forms  of  electrothera]>eutics  are  not  universall\'  recognized  by 
urologists  while  the>'  empkn'  so  widely  this  treatment  in  the  currents 
of  Oudin  and  d'Arsonval.  This  situation  undoubtedly  arises  from  the 
fact  that  the  methods  of  applying  the  latter  two  modalities  have  been 
studied  and  refined  while  those  of  employing  other  forms  have  been 
neglected. 

Varieties. — Electricity  is  in  local  or  general  applications  and  is  further 
distinguished  by  the  form  of  current.  The  local  t^pes  are  urethral, 
rectal  and  abdominal.  The  kinds  of  current  are  galvanic  or  direct, 
faradic  or  induced,  static  or  frictional,  Oudin  or  unipolar  high  frequency, 
d'Arson^■al  or  bipolar  high  frequency  and  diathermy,  which  is  the 
direct  application  of  the  d'Arsonval  current.  In  lu-ology  faradism  is 
comparatively  little  used. 

Action. — ^The  physiological  acti^•ities  evoked  differ  greatly  with  the 
various  currents  applied  as  discussed  under  each  in  the  following 
paragraplis. 

Galvanism  or  the  Direct  Current. — Action. — In  galvanism  or  the  direct 
current  the  chief  value  is  cataphoresis.  The  current  is  electrolytic 
to  metal  electrodes  and  therefore  deposits  in  the  tissues  oxVchloride  of 
the  metal  used  when  the  positi\'e  pole  is  applied  to  the  diseased  tissue. 
When  the  negative  pole  is  used  the  alkalies,  alkaloids  and  the  halogen 
group  should  be  added.  The  chemical  strength  of  these  medicaments 
is  always  very  weak  and  that  of  the  galvanic  current  varies  from  3  to  5 
milliamperes  and  so  rarely  more  as  to  be  at  least  for  the  novice  never  more. 

The  positive  pole  contracts  and  stimulates  and  the  negative  i)ole 
of  galvanism  relaxes  and  (juiets.  In  spasm,  therefore,  of  the  urethra, 
for  example  after  using  the  positive  pole,  the  negative  current  should 
be  turned  on  in  the  same  strength  and  for  the  same  duration  or  until 
the  contraction  relaxes. 

Indications. — Galvanism  is  serviceable  wherever  a  deposit  of 
astringent  and  stimulating  medicament  is  required  for  the  tissues. 
There  should  be  no  imfavorable  aftereffects. 

Faradism  of  the  Induced  Current. — Action.  — h\  faradism  or  the 
induced  current  the  muscle  substance  is  stimulated  and  for  good  results 
the  contraction  must  correspond  with  the  rapidity  of  muscular  fibrilla- 
tion, which  is  30  per  second. 

Indications. — Faradism  is  indicated  whenever  there  is  relaxation  of 
muscular  or  other  tissue.    Exhaustion  should  not  be  an  aftereffect. 


PHYSICAL  MEASURES  501 

Oudin  or  the  Unipolar  High-Frequency  Current. — Action. — The  Oudin 
or  the  unii)()liir  higli-fre(|iieiicy  eurreiit  Jims  its  efi'eets  aceording  to  the 
spark-gap,  from  drying  to  charring. 

I'est. — ^The  best  test  is  with  a  piece  of  soaj),  as  follows: 

1.  Take  a  piece  of  dry  ivory  soap  and  adjust  the  spark-gap  so  that 
the  soap  is  dehydrated.  It  then  puffs  up  into  a  dry,  fine,  white  powder. 
It  should  not  be  discolored  or  charred. 

2.  If  in  doubt,  cover  the  soap  with  a  piece  of  paper,  which  will  burn 
if  the  spark  is  too  hot,  otherwise  it  will  permit  the  spark  to  jump 
through  it  without  damage  to  the  paper  and  with  dehydration  of  the 
soap. 

3.  For  caustic  effect  increase  the  spark-gap  until  the  soap  bubbles 
and  coagulates  but  does  not  char. 

4.  For  carbonization  the  spark-gap  is  increased  until  the  soap  is 
coagulated  and  then  blackened  by  charring. 

Indications. — The  graduations  in  the  strength  of  this  current  are 
by  this  test  absolute  and  make  it  available  for  the  stimulation  and 
healing  of  ulcers  or  the  carbonization  of  new  growths.  The  electrode 
with  its  wire  slightly  projecting  will  destroy  and  then  permit  to  heal 
diseased  follicles  of  the  paraurethral,  periurethral,  urethral,  preputial 
and  vesicle  in  either  sex  by  insertion  into  the  cavity  of  the  follicle. 

Aftereffects. — There  is  no  cicatrix  of  the  deep  infiltrating  type  as 
after  incision  and  the  galvano  or  the  actual  cautery. 

D'Arsonval  or  Bipolar  High-Frequency  or  Alternating  Current. — Action. 
— ^The  d'Arsonval  current  causes  direct  diatherni}-  and  also  indirect 
diathermy  with  an  auto  condensation  couch  as  the  dispersing  electrode. 
This  method  is  the  one  employed  for  dilating  stricture  of  the  ureter  or 
urethra. 

Strength. — The  current  should  be  from  100  to  200  milliamperes  and 
without  pain.  More  than  a  gentle  tingling  is  not  desirable.  The  test 
is  for  the  operator  himself  to  get  upon  the  autocondensation  couch 
and  to  apply  the  active  electrode  to  the  tongue,  which  should  feel  a 
painless  glow\ 

Indications. — Infiltrations  and  strictures,  the  urethra  and  ureter 
by  mdirect  diathermy,  and  by  direct  diathermy  it  is  available  in  local 
inflammations. 

Diathermy.  —  Origin.  —  The  bipolar  high-frequency  current  of 
d'Arsonval  causes  diathermy,  which  is  briefly  a  heat  influence. 

Forms. — Direct  diathermy  if  when  soft,  malleable,  metal  electrodes 
are  applied  to  opposite  sides  of  the  part  as  the  knee,  or  when  an  organ 
like  the  penis  is  wrapped  in  such  an  electrode.  Careful  apposition  of 
the  metal  to  the  skin  is  essential  in  order  to  avoid  biu:ns  which  are 
difficult  to  heal. 

The  indirect  diathermy  is  secured  when  the  active  electrode  is  applied 
to  the  affected  part  with  distribution  of  the  current  tkrough  the  whole 
body  by  having  the  autocondensation  couch  act  as  the  dispersing 
electrode. 


502  GEXERAL  PRIXCII'LES  OF  TREATMEXT 

Indicaiio)is. — Any  acute  or  subacute  infectiou  which  will  be  bene- 
fited by  the  local  increase  of  temperature  ami  leukocytosis,  and 
phagocytosis  for  combating  and  destroying  the  organisms. 

A  review  of  literature  contains  many  observations. 

De  Kraft'  reviews  diathermy  as  follows.  Roccayror-  em})loyed 
diathermy  in  chronic  luvthritis  with  special  thermophores.  The  g«)uo- 
coccus  was  killed  at  3!>°  ('.  in  twenty  minutes.  The  thermophores 
in  the  urethra  are  connected  to  one  side  of  the  diathermy  machine. 
The  other  electrode  (metallic  plate)  is  placed  on  the  buttocks,  penis 
or  perineimi.  In  44  cases  he  variously  relieved  pain,  shreds,  soft 
infiltrations  and  trophic  changes. 

Geyser''  applying  steel  sounds  as  lu'cthral  electrodes  and  tempera- 
tures around  108°  F.  with  diathermy  for  one  hour  daily  for  three  days 
killed  the  gonococcus.  Eitner^  found  that  gonococci  disappear  in  acute 
uretin-itis  after  a  time  under  diathermy  for  forty  minutes  twice  daily. 
The  urine  remained  cloudy  and  after  cessation  of  treatment  the  organ- 
isms returned,  but  the  measures  removed  subjecti\'e  symptoms. 
Santos*  showed  that  gonococci  die  in  seventy-six  minutes  at  43°  C, 
in  fift\'-fonr  minutes  at  44°  C.  and  in  thirty-seven  minutes  at  45°  C, 
and  that  animals  and  human  beings  can  bear  a  temperature  of  45°  C. 
and  even  40°  C,  for  one  hour  without  discomfort  or  damage.  After 
many  trials  and  with  much  difficulty  he  constructed  an  electrode  which 
heated  the  urethra  throughout  and  sterilized  a  gonorrhea  of  several 
weeks'  duration  in  a  single  ninet>'-minute  sitting.  In  a  second  case  a 
second  treatment  cured.  In  three  other  cases  no  result  could  be 
achieved. 

Ballenger  and  Elder'"'  devisefl  a  ball  electrode  for  the  d'Arsonval 
current  in  folliculitis.  Kaufman'  urethroscopes  carefully.  The 
electrode  is  inserted  into  the  follicle  up  to  definite  resistance.  The 
current  is  then  turned  on  for  one  second.  Usually  two  or  three  one- 
second  periods  cure.    The  results  were  excellent  in  5  cases. 

De  Kraft^  himself  has  treated  spasmodic  strictures  with  an  ordinary 
sound  as  one  electrode,  and  a  wrai)ping  of  tin-foil  on  the  penis  as  the 
other  electrode.  Neurasthenia  depending  on  a  chronic  congestive 
prostatitis  may  be  relieved  by  a  metallic  prostatic  electrode  in  the 
rectum,  connected  to  one  pole  of  the  diathermic  apparatus;  while  a 
metal  plate  above  the  symphysis  is  attached  to  the  other  pole.  Indura- 
tions are  benefited  by  diathermy  through  a  metallic  sound  from  witiiin 
and  a  flexible  tin-foil  electrode  on  the  outer  surface  of  the  organ.  Incon- 
tinence in  older  men  in  atony  of  the  sphincter  or  m  the  chronic  vesical 
irritation  of  diabetes  mellitus  is  decreased  by  diathermy  through  a 

1  Am.  .lour.  Electrother.  and  Radiol.,  November,  1917. 

2  Bull,  de  I'Academie  de  Medecine,  May  22,  1917. 
»  New  York  Med.  Jour.,  June  30,   1917. 

*  Jour.  Adv.  Therap.,  March,  1917. 

'  In  Boerner  and  Santos:    Med.  Kliiiik,  June  21,  1914,  x,  10G2. 
»  Jour.  Am.  Med.  Assn.,  May  27,  1916. 
'  New  York  Med.  Jour.,  March  24,  1917. 

*  Loc.  cit. 


MEDICINAL  MEASURES  503 

metallic  electrode  in  the  rectum  and  metal  plate  over  the  bladder. 
Canovas'  applied  diathermy  in  73  cases  of  gonococcic  orchitis  and 
epididymitis.  It  sm-passes  all  other  methods.  It  relieves  pain  at  once 
and  cm-es  in  three  or  fom-  applications.  The  diathermy  reduces  inflam- 
mation and  kills  the  gonococci.  The  genital  functions  remain  unim- 
paired. 

It  therefore  appears  from  all  the  foregoing  studies  that  diathermy 
possesses  a  wide  field  of  development. 

MEDICINAL  MEASURES. 

Classification. — vSelection  of  medicines  in  gonococcal  as  in  other 
infections  depends  on  the  stages  of  the  disease,  acute,  subacute  and 
chronic  and  on  the  presence  or  absence  of  complications.  It  further 
varies  with  the  methods  of  local  application  and  systemic  administra- 
tion, which  include  orrhotherapy. 

Acute  Stage. — In  the  acute  period  are  indicated  sedatives,  urinary 
diluents,  neutralizers  and  antiseptics  and  antiblennorrhagics,  because 
the  mucosa  is  violently  inflamed  and  its  secretion  profoundly  altered. 

Acting  by  systemic  administration  after  absorption  into  the  blood, 
the  sedatives  quiet  the  congestion  and  the  irritation  by  their  direct 
antispasmodic  influence.  The  belladonna  group  and  the  opium  group 
are  the  most  reliable  examples.  By  dilutmg  and  neutralizing  the  urine 
the  inflammation  is  also  quieted  so  that  among  the  sedatives  should 
be  classed  the  urmary  diluents  and  neutrahzers.  The  ordinary  alkalies, 
mineral  waters  and  even  plain  table  water  are  of  service.  Except  for 
infections  in  closed  cavities  like  the  pelvis  of  the  kidney  and  the  bladder 
the  urinary  antiseptics  have  little  or  no  value.  Under  this  heading 
belong  the  drugs  which  produce  formaldehyde  by  being  split  up  in  the 
body.  Hexamethylenamin  and  its  allies  are  most  familiar  and  act 
best  when  combined  with  equal  quantities  of  benzoate  of  soda. 

Acting  by  topical  application  to  the  mucosa  a  sedative  and  decon- 
gestive  influence  is  seen  by  the  heat  of  sitting  baths  and  of  properly 
selected  irrigation  of  normal  salt  solution  and  if  the  fluid  is  also  anti- 
septic, such  as  potassium  permanganate,  argyrol  or  other  silver  salts, 
the  infection  as  such  is  combated.  The  latter  influence  belongs  to 
hand  injections  because  their  quantity  is  usually  not  suSicient  to  make 
their  heat  of  value.  The  aim  is  not  to  flare  up  the  inflammation,  but 
to  correct  it  by  heat  within  tolerance,  by  mild  strengths,  by  copious 
quantities  w^ithin  common  sense,  by  frequencj^  according  to  response, 
by  retention  for  a  full  influence  of  heat  and  drug  and  by  gentleness  of 
application,  s  :>  that  the  syringe-and-catheter  method  is  to  be  preferred 
to  the  irrigator  method.  All  these  details  are  elucidated  in  the  para- 
graphs on  hand  injections  and  irrigations  m  the  Chapter  on  Acute 
Urethritis  on  pages  61  to  64. 

The  antiblennorrhagics  are  of  value  in  some  acute  cases  and  they  com- 

1  Diag.  Med.,  June  30,  1917. 


504  GEXERAL  PRIXCIPLES  OF  TREATMENT 

prise  the  balsams  ami  the  oils  and  the  oleoresiiis.  Their  action  is  by 
stimnlatino-  an  hidolent  mucosa  to  a  proper  degree  and  quality  of  secre- 
tion. Tlieir  list  is  a  long  one  but  familiar  are  copaiba,  cubeb,  sandal- 
W'ood  oil  and  oil  of  tnrjjentine.  (lomenol  oil  is  a  new  product  of  great 
service  esi>ocially  in  kidney  and  bladder  conditions.  The  doses  of  all 
these  products  must  not  irritate  the  digestion  or  the  kidneys,  as  respec- 
tively indicated  by  eructations  and  anorexia  as  to  the  stomach  and  by 
pain  or  frequency  of  urination  as  to  the  kidneys. 

Chronic  Stage. — In  tliis  jieriod  the  nnicosa  is  infiltrated,  relaxed 
and  inacti\  e.  Its  secretion  is  thick  and  imnatural.  Stimulants,  anti- 
septics and  astringents  are  required. 

The  stimulants  by  internal  admuiistration  are  again  chiefly  the  oils, 
balsams,  resins  and  oleoresins.  These  reach  their  greatest  value  in 
chronic  instead  of  acute  lesions.  The  doses  are  mild  and  increasing 
according  to  the  modification  of  the  mucus.  They  must,  as  just  stated, 
not  irritate  the  kidneys  or  the  digestion.  Combinations  of  several 
of  these  drugs  m  small  doses  are  therapeutically  more  valuable  and 
practically  Avithout  aftereffects. 

By  local  administration  the  eft'ects  of  antiseptics  and  astringents 
are  sought.  They  increase  the  blood  flow  and  correct  the  boggy 
granulations  and  indolence. 

The  antiseptics  by  mternal  administration  pm'ify  the  urine,  but  as 
stated  in  the  paragraph  on  the  acute  period  they  are  of  more  value  in 
infections  of  the  kidney,  ])elvis,  ureter  and  bladder.  It  is  doubtful 
whether  the  mere  bathing  of  the  mucosa  of  the  urethra  has  any 
influence,  although  the  urine  is  strongly  antiseptic. 

By  local  administration  the  antiseptics  are  available  in  injections, 
ii'rigations,  instillations  and  applications.  Of  these  the  last  two  are 
of  greatest  value  because  a  small  quantity  of  relatively  strong  fluid 
is  as  far  as  possible  applied  directly  to  the  diseased  zone. 

The  astruigents  are  mhieral  or  vegetable.  At  least  the  early  strengths 
are  weak  and  are  slowly  augmented.  There  must  be  no  overstimula- 
tion, reaction,  pain  or  great  exfoliation  of  epithelia.  Relatively  fre- 
quent repetition  and  long  retention  are  to  be  preferred  to  the  stronger 
concentration.  The  mineral  astringents  are  much  the  best  and  the 
common  three  are  the  salts  of  siher,  zinc  and  copper.  It  is  probable 
that  nitrate  of  silver  which  is  ranked  as  the  most  astringent,  the  least 
irritating  and  the  least  caustic  is  the  best  and  that  a  proper  strength 
of  it  for  each  patient  can  always  be  found.  The  vegetable  astringents 
are  of  much  less  value  through  superficial  action. 

Systemic  Administration. — The  aims  of  this  form  of  treatment  are 
to  influence  the  activity  of  the  local  circulation  in  the  inflammation 
by  changes  in  the  whole  system  through  the  condition  of  the  blood- 
stream itself,  the  urine  and  the  nervous  system.  Circulatory  sedatives 
are  therefore  in  order,  while  stimulation  is  avoided — through  coffee, 
tea,  cocoa  and  more  particularly  alcoholics,  among  the  connnon  drugs. 
Physiological  influence  is  equally  unportant  so  that  direct  and  indirect 
sexual  excitement  must  be  forbidden.    It  is  in  these  details  that  the 


MEDICINAL  MEASURES  505 

cooperation  of  the  patient  is  so  important,  })ut  difficult  and  at  times 
impossible  to  obtain.  The  minute  principles  of  systemic  administra- 
tion and  allied  to]ncs  are  laid  down  in  the  treatment  of  each  lesion  in 
the  chapters  on  Acute  Urethritis,  Chronic  Urethritis  and  Complications. 

In  serumtherapy  we  approach  a  subject  of  modern  knowledge  and 
great  importance.  It  is  discussed  in  the  sections  on  serum-diagnosis  and 
serumtherapy  in  Chapter  VIII  on  General  Principles  of  diagnosis  on 
page  475.  Under  this  heading  are  included  administration  of  serum  and 
bacterin.  Of  the  latter  there  are  two  general  classes:  the  autogenous 
as  derived  from  the  patient's  own  infecting  organisms,  and  hetero- 
geneous as  obtained  from  other  sources.  Either  or  both  may  be  a  pure 
culture  of  the  gonococcus  alone  or  of  this  organism  combined  with 
many  other  pus-producing  germs.  The  latter  preparations  are  known 
as  the  mixed  or  combined  bacterins.  In  general,  persistent  treatment 
with  the  serum  or  the  bacterin  is  necessary  in  gonococcal  infections 
and  on  the  whole  this  therapy  is  less  efficient  in  gonococcal  than  in 
other  diseases. 

Local  Administration. — ^This  method  of  treatment  affects  in  the  male 
the  prepuce,  gians,  meatus,  urethra,  bladder,  ureters  and  kidneys. 
Accessible  in  the  female  are  the  vulva,  vagina,  cervix  and  cavity  of  the 
uterus,  as  well  as  the  urethra,  bladder,  ureters  and  kidneys.  The 
urethral  methods  in  both  sexes  are  irrigations,  retrojections,  injections, 
instillations  and  applications  in  the  technics  already  described  in  the 
paragraphs  on  the  treatment  of  appropriate  lesions.  The  urethroscope 
and  cystoscope  are  means  of  modern  and  approved  treatment  which 
must  never  be  overlooked  in  this  field  of  cure.  The  rule  should  again 
be  repeated  that  mild  solutions  applied  at  relatively  short  intervals 
and  as  far  as  possible  retained  for  long  periods  are  more  efficient  and 
reliable  than  strong  medicaments  applied  at  long  intervals  and  not 
at  all  retained.  The  latter  are  very  apt  to  cause  a  chemical  inflam- 
mation which  adds  to  any  infection  present. 

The  ureteral  and  renal  steps  are  those  of  the  cystoscope,  ureteral 
catheterization,  pelvic  lavage  and  instillation.  The  latter  two  methods 
may  also  be  applied  to  the  ureter.  One  cannot  repeat  here  the  technic 
described  under  the  proper  headings  in  the  chapters  on  Urethroscopy 
and  Cystoscopy  on  pages  616  and  682;  but  the  rule  of  gentleness  just 
reiterated  in  the  preceding  paragraph  applies  with  equal  and  added 
force  and  particularly  bears  on  the  detail  of  not  offendmg  the  mucosa 
by  undue  dilatation  of  the  pelvis  or  ureter. 

For  vaginal  methods  the  various  specula,  such  as  Sims',  Ferguson's, 
and  the  bivalve  and  the  various  douches,  are  available.  The  mucosa 
of  the  vagina  is  much  more  resistant  than  that  of  other  parts  of  the 
genital  track  so  that  stronger  and  hotter  solution  may  be  advisedh' 
used  but  never  with  severe  reaction  which  would  intensify  the  infection. 

In  the  uterine  technic  mild  cautious  douches  may  be  employed, 
always  provided  that  there  is  free  outlet  and  no  obstruction  to  the 
return  flow,  so  that  retention  woLild  follow  with  extension  to  the  tubes. 
The  oviducts  should  not  be  invaded  with  fluids  by  methods  at  present 


506  GEXERAL  PRIXCIPLES  OF  TREATMENT 

inailaMo.  A])])lications  on  cotton-wound  wire  sounds  with  small 
(luantitios  of  stronger  medicaments  may  be  employed.  In  the  vagina 
and  the  uterus,  as  in  all  other  mucous  membranes,  mild  frequent  treat- 
ments are  better  than  se\ere  infrequent  attempts  because  the  latter 
are  often  followed  by  intense  reactions  and  extensions  of  the  disease, 
whereas  the  former  are  not.  The  great  caution  in  the  uterus  must  be 
good  drainage,  weak  solutions  antl  slow  ascent  in  strength.  Frequency 
and  persistence  rather  than  rare  and  irregular  attention  are  required. 

SURGICAL  MEASURES. 

Classification. — Nonoperative  and  operative  procedures  are  dis- 
tinguishctl  muler  the  heading  of  surgical  measures,  which  include  more 
or  less  definite  instrumentation  even  when  no  actual  cutting  is  done. 

Nonoperative  Means. — These  include  dressings,  catheterization, 
urethral  irrigation,  lu'ethral  instillations,  urethral  retrojections,  hand 
injections,  straight  sounds,  irrigating  sounds,  instillating  sounds, 
mechanical  dilators  and  ointment  sounds. 

The  dressings  are  penile,  preputial  and  ^■ldvar  so  far  as  urethritis 
and  allied  conditions  are  concerned  and  therefore  the  description 
excludes  the  dressings  of  the  major  operations,  under  which  they  are 
described.  The  object  of  dressings  is  to  receive  the  discharge,  as 
voided,  keep  the  skin  and  clothing  clean  and  prevent  mediate  infection 
of  the  eyes  of  the  patient  and  the  eyes  of  innocent  persons  or  their 
sexual  systems.  Their  purpose  is  distinctly  not  to  retain  discharge,  as 
such  retention  extends  the  infection.  In  the  male  the  penile  gauze  bag 
or  the  gauze  hood  as  explained  in  the  paragraphs  on  the  treatment  of 
acute  lu'ethritis  on  page  55  is  available.  The  hood  is  the  jweputial 
dressing  in  balanitis  and  similar  complications.  A  cotton  plug  over 
the  meatus  within  the  foreskin  bottles  up  the  discharge,  extends  the 
inflammation  in  depth  and  along  the  urethra  and  is  contraindicated. 
Likewise  the  j^lug  of  cotton  in  the  cleft  of  the  vulva  in  the  female, 
which  should  be  supplanted  by  the  loose  gauze  pad.  All  dressings 
should  be  frequently  changed  and  retention  if  ])resent  relieved  by 
urination,  irrigation,  hand  injection  or  douche. 

No  catheterization  should  be  attempted  in  acute  lesions  of  the  urethra 
except  anterior  irrigation  with  a  very  small  catheter  in  the  syringe-and- 
catheter  method.  It  is  likewise  contraindicated  in  chronic  urethritis 
with  positive  infection  unless  irrigation  of  both  bladder  and  urethra 
follows.  In  fact,  it  is  best  to  irrigate  these  parts  after  any  instrumenta- 
tion. Catheterization  with  small  soft  instriunents  may  be  gently 
attempted  in  acute  retention  but  must  not  be  persisted  in  more  than 
one  or  two  invasions.  Irrigation  of  the  bladder  and  canal  must  follow. 
The  best  antiseptic  solution  is  silver  nitrate,  1  to  5000  to  1  to  2000,  in 
reasonably  hot  water.  The  forms  of  catheter  are  well  known  to  every 
skilled  urologist.  I'he  soft-rubber  instruments  are  l)etter  the  nearer 
the  acute  period  the  lesion  is  and  they  must  be  new,  elastic  and 
smooth.     Rubber  hardens,   drys  and  cracks  with   age   with   result- 


HURGICJAL  MEASURES  507 

ing  inelasticity,  roughness  and  irritation.  The  woven  catheters  are 
better  in  the  later  periods  l)ecause  they  improve  treatment  by  their 
various  forms  selected  according  to  the  case.  Their  surfaces  must  also 
be  without  cracks.  The  storing,  care  and  sterilization  of  these  instru- 
ments are  described  for  the  more  important  varieties.  Good  lubrica- 
tion is  necessary  and  the  author  thinks  that  glyceritum  boroglycerini 
or  any  of  the  soft  Irish  moss  preparations  is  the  best.  It  is  certain 
that  these  are  soluble  in  water  and  do  not  coat  the  mucosa  so  that 
applications  lose  their  penetrating  power. 

The  ui-ethral  irrigations  are  performed  by  the  manual  or  the  gravity 
methods.  The  syringe-and-catheter  method  is  the  choice,  of  the  author, 
because  it  is  the  most  gentle  and  precise  and  permits  the  educated 
hand  to  perceive  how  much  resistance  is  encountered  and  how  much 
pressure  the  mucosa  will  tolerate.  The  gravity  technics  are  repre- 
sented by  the  Chetwood  double-current  and  the  Valentine-Janet 
equipments.  Of  these  the  Chetwood  is  the  choice  of  the  author 
although  both  have  their  strong  advocates.  In  general  the  pressure  of 
the  fluid  must  not  be  greater  than  that  of  the  urine  as  it  passes  through 
the  canal.  This  rule  avoids  traumatism  of  the  severely  inflamed  mucosa. 
These  procedures  are  detailed  in  appropriate  paragraphs  on  treatment 
of  Acute  and  Chronic  Urethritis  on  pages  64  and  282.  It  is  noted  that 
irrigations  apply  to  copious  quantities  and  the  rather  earlier  periods  of 
the  disease  in  which  flushing  with  a  mild  concentration  of  chemical  is  in 
order.  They  may  be  given  once  or  twice  daily  and  as  adjuvants  the 
hand  injection  is  important. 

The  urethral  instillations  are  otherwise  employed  with  small  quanti- 
ties of  much  stronger  solutions  and  in  the  late  subacute  and  chronic 
periods.  Both  the  anterior  and  the  posterior  urethra  may  be  reached 
by  this  method.  In  the  author's  judgment  the  soft-rubber  catheters, 
size  10  or  12  F.,  6  inches  long  with  a  4  drachm  s^Tinge  of  the  Hayden 
type  or  the  author's  modification  of  it,  are  the  best  for  the  anterior 
urethra.  In  the  posterior  lu-ethra  the  soft-rubber  catheter  may  again 
be  employed  but  with  less  satisfaction  than  the  syringe  of  Keyes's 
modification  of  the  original  Ultzmann  type  or  still  better  the  Bangs 
syringe  sound,  which  in  having  a  full  set  of  tips  adds  gentle  dilatation  to 
the  medication.  Agam  nitrate  of  silver  is  the  best  for  the  average  case. 
No  strength  should  be  selected  which  causes  chemical  inflammation. 
From  weak  solutions  such  as  1  to  5000  with  which  the  treatments 
begin,  ascent  should  be  gradual  and  its  results  closely  observed.  Under 
the  subject  of  the  treatment  of  lesions  will  be  found  the  details  of  the 
instruments,  technic  and  solutions.  Every  other  day  is  the  proper 
inter^'al  and  dilatation  with  somids  and  electrotherapy  are  usual 
adjuvants. 

The  urethral  retrojections  involve  the  use  of  a  reflux  catheter  or  the 
filling  of  the  bladder  with  the  solution  which  the  patient  voids  as 
though  it  were  urme.  The  varieties  of  reflux  catheter  are  familiar  and 
their  use  is  cautious.  The  method  of  fiUmg  the  bladder  is  to  be  pre- 
ferred and  masmuch  as  cases  requiring  retrojections  are  also  bene- 


508  GENERAL  PRINCIPLES  OF  TREATMENT 

fited  by  tlilatations,  tlie  author's  irrigating'  sounds  are  the  best  possible 
method  of  combining  both  treatments.  The  sound  is  described  on  ])age 
oliS  and  retrojections  Avith  its  aid  are  fully  noted  under  dilatation  of 
stricture  on  j)age  o70.  Again  the  rule  applies  of  using  lluids  hot  within 
tolerance,  copious  within  comfort  and  concentrated  within  any  reac- 
tion. Frequency  with  the  soft  catheter  may  be  every  other  day  and 
with  the  sound  every  five,  seven  or  ten  days.  Instillations  are  good 
alternates. 

The  hand  injection  is  apjjlied  by  the  patient  himself  according  to 
printed  directions  in  order  to  avoid  excesses  in  frequency,  activity  or 
force.  The  proper  syringe  is  very  imi)ortant  and  the  best  types  are 
shown  on  ])age  4*).  Care  should  be  taken  that  the  ])atient  secures 
the  cone-])oint  urethral  tA-jJc  and  not  such  forms  as  the  druggist  may 
supply.  The  author  has  seen  nose,  ear  and  e\'en  rectal  syringes  sold  to 
patients.  The  instructions  to  patients,  the  list  of  solutions,  the  period 
of  choice  for  injections  are  all  presented  in  the  paragraphs  on  treatment 
of  Acute  I'rethritis  on  j)age  72.  According  to  reaction  the  patient 
uses  from  two  to  six  injections  daily.  Antiseptic  solutions  gradually 
give  way  to  astringents. 

The  straight  sounds  introduce  the  subject  of  instrumentation  of 
the  urethra  for  dilatation  and  massage  of  the  nnicosa.  The  standard 
sounds  passed  only  to  the  bulb  of  the  lU'ethra  will  thus  treat  the 
anterior  section  of  the  canal  but  the  straight  sound  as  shown  on  page 
2S4  is  much  to  be  preferred.  These  instruments  should  ne\'er  be 
used  while  infection  is  present  but  only  when  the  catarrhal  period  is 
developed  and  when  massage  along  the  canal  upon  the  sound  stimu- 
lates the  indolent  membrane.  The  dilatation  should  never  be  more 
than  one  or  possibly  two  numbers  of  the  French  scale  at  each  treatment, 
and  the  frequency  of  treatments  should  be  about  once  in  seven  days, 
rarely  once  in  five  days  and  sometiiues  once  in  ten  days.  Greater 
energy  of  treatment  may  defeat  its  purpose  and  make  it  harmful. 
The  sounds  are  best  used  cold. 

The  irrigating  and  instillating  sounds  have  already  been  sufficiently 
noted  under  retrojections  and  posterior  urethral  instillations  in  para- 
graphs immediately  preceding.  All  further  facts  are  found  in  the 
I)aragra])hs  on  the  use  of  sounds  for  treatment  of  Chronic  Urethritis 
and  Stricture  on  pages  287  and  365. 

The  mechanical  dilators  have  long  been  considered  instruments  of 
danger.  They  become  such  only  wlien  the  degree  of  dilatation  is  greater 
than  one  or  possibly  two  numl)ers  of  the  French  scale  at  a  sitting  and 
when  the  frequency  exceeds  the  five-day  interval  as  the  shortest. 
The  irrigating  and  nonirrigating  types  are  in  common  use  as  detailed 
under  the  treatment  of  Chronic  I'rethritis  and  Stricture. 

The  ointment  sounds  vary  between  the  cupi)ed  sound  carrying  the 
ointment  in  the  recesses  and  the  tubular  which  express  the  ointment  in 
mass  at  any  point  of  the  canal.  The  urethra  reacts  to  the  ointment 
as  to  a  foreign  body  and  expresses  practically  all  of  it.  The  remainder 
is  not  absorbed  to  any  serviceable  degree.    The  ointment  sound  of 


SURGICAL  MEASURES  509 

the  autlior,  as  shown  on  page  295,  is  the  best  model  and  permits  the 
medicine  to  be  applied  to  given  points.  The  formulae  of  the  ointments 
and  the  frequency  of  application  are  detailed  in  the  paragraphs  on 
treatment. 

Operative  Measures. — Under  this  heading  are  included  the  more 
definite  procedures  which  may  or  may  not  require  local  anesthetics 
and  may  or  may  not  involve  incisions.  The  list  includes  urethroscopy, 
cystoscopy,  catheterization  of  the  ureters,  urinary  segregation,  minor 
operations  and  major  operations.  All  such  technic  should  have  fore- 
treatment  and  aftertreatment  as  the  means  of  preventing  unfavorable 
reaction  or  of  checking  it  at  its  earliest  possible  signs. 

The  sciences  of  urethroscopy  and  cystoscopy  are  so  definite  that 
each  is  considered  as  separate  subjects  in  Chapters  XII  and  XIII. 

The  catheterization  of  the  ureters  is  one  of  the  procedures  belonging 
to  cystoscopy  and  may  be  so  safely  performed  that  it  should  be  a  routine 
examination  in  every  case  of  unexplained  blood,  pus,  gravel  or  other 
signs  in  the  urine  or  of  pain  anywhere  in  the  abdomen  not  otherwise 
explained.  The  shadow  catheter  is  the  one  means  of  making  the 
.r-ray  findings  unmistakable  in  cases  of  suspected  stone.  There  are 
twenty-one  shadows  which  have  been  mistaken  for  stones  in  the  pelvis 
or  ureter  and  their  list  is  given  in  the  section  on  Lithiasis  of  the  Kidney 
on  page  923.  Other  data  of  this  subject  are  given  under  Cystoscopy 
on  page  682. 

The  urinary  segregators  aim  to  separate  the  urine  from  the  two 
kidneys  while  being  collected  in  the  bladder.  The  only  serviceable 
ones  are  Harris's,  Cathelin's  and  Luys's.  The  general  principle  of 
each  erects  a  median  dam  in  the  bladder  between  the  two  ureters  and 
provides  an  outlet  for  each  half  of  the  viscus  thus  formed.  Color 
tests  show  that  often  the  two  sides  leak,  so  that  a  definite  diagnosis 
cannot  be  relied  on.  Of  the  three  mentioned  the  Luys  instrument  is 
the  best  and  is  discussed  under  Cystoscopy  on  page  704.  When  com- 
pared with  ureteral  catheterization  the  segregator  is  a  very  misatis- 
factory  instrument. 

The  minor  operations  are  in  general  those  that  are  solely  or  chiefly 
done  under  local  anesthesia,  although  the  modern  technic  of  infiltra- 
tion of  the  skin,  fascia  and  muscle  planes  with  dilute  cocaine  solution 
and  spinal  injections  of  cocaine  derivatives,  have  made  many  operations 
come  within  the  reach  of  local  anesthetics.  The  mmor  operations  as  a 
rule  do  not  requu-e  the  forecare  as  to  the  bowels  by  catharsis  and  starva- 
tion, but  the  same  rigid  asepsis  and  antisepsis  are  necessary.  In  the 
gonococcal  lesions  the  minor  operations  are  superficial  and  include 
circmncision,  meatotomy  and  adenotomy  as  examples.  Aftertreat- 
ment is  usually  concerned  only  with  dressings. 

The  major  operations  are  characterized  by  forecare  often  for  long 
periods  as  well  as  the  day  before  the  operation,  by  general  anesthetics 
and  by  in^^asion  of  the  important  organs,  such  as  the  kidneys,  ureters 
and  bladder.  The  aftercare  of  these  cases  mcludes  not  only  the  dress- 
ings of  the  field  but  also  attention  to  the  urinary  system  as  a  whole. 


510  GENERAL  PRINCIPLES  OF  TREATMENT 

Aftertreatment. — ^This  is  a  subject  entirely  too  iimcli  iiejjiected  in  the 
average  text-book,  article  in  literature  or  discussion  in  medical  societies. 
It  comprises  both  immediate  and  remote  aftercare.  The  immediate 
aftertreatment  is  that  of  the  wound  in  dressings,  of  the  urinary  organs 
imder  the  surg'cal  interference,  and  of  the  system  in  general  in  the 
recovery.  The  dressings  may  persist  for  many  weeks  but  the  other 
details  involve  a  few  days  of  attention  to  the  excretion  of  urine  in 
quantity  and  quality,  and  freedom  from  obstruction  of  outflow  as  in 
kidney,  ureteral  and  bladder  work.  The  system  at  large  during  the 
iirst  few  days  nnist  relie\e  the  kidneys  in  many  cases  tln-ough  the  bowels 
and  the  skin. 

The  remote  aftertreatment  aids  the  diseased  organ  to  recover  from 
the  lesion  as  far  as  possible  after  the  initial  aid  afforded  by  the  opera- 
tion. The  best  exam])le  is  care  of  the  bladder  to  relieve  the  cystitis 
accompanying  enlargement  of  the  prostate,  lithiasis  and  malignant 
neoplasm.  Pyelitis  often  requires  drainage  through  the  loin  and  is  a 
disease  analogous  to  cystitis  in  the  long  attention  necessary  to  the 
mucosa  through  the  urinary  antiseptics,  ])roper  diet  and  gentle  lavage 
of  the  pehis  and  ureter. 

Cure. — The  relief  of  a  disease  is  jjathologic,  symptomatic  and  bac- 
teriologic  and  the  term  cure  may  be  used  somewhat  similarly  to  prog- 
nosis. The  lesions  of  gonococcal  disease  are  so  penetrating  that  the 
pathologic  results  are  often  not  entirely  remediable  but  the  remaining 
lesions  are  so  little  that  the  patient  is  symptomatically  cured.  Stric- 
ture is  an  example  of  a  pathologic  sequel  which  as  a  cicatrix  in  the 
mucosa  is  never  changed.  The  victim  of  stricture  may  have  few 
or  many  symptoms  and  even  directly  fatal  complications.  The  bac- 
teriologic  cure  is  for  the  community  quite  as  important  and  in  some 
respects  more  important  than  it  is  for  the  individual  patient.  The 
reason  is  that  the  gonococcus  and  its  allies  may  reside  in  the  mucosa 
for  months  and  years  with  little  inconvenience  to  the  patient  but  with 
high  infectiousness  to  the  mate  in  wedlock.  No  man  or  woman  should 
])e  allowed  to  marry  after  an  infection  until  rigid  and  repeated  labora- 
tory investigations.  A  most  important  detail  is  the  double  examina- 
tion of  each  sex  in  the  quiescent  and  active  states.  This  subject  is 
more  fully  detailed  under  Prophylaxis  on  page  4S3. 

TREATMENT  OF  THE  COMPLICATIONS  OF  URETHRITIS. 

Varieties. — ^A^arieties  are  as  previously  described  in  this  work  the 
nongonococcal  and  the  gonococcal,  of  which  the  latter  is  the  established 
type  to  which  the  others  are  compared.  Furthermore,  complications 
are  recognized  as  to  extension  anterior  urethral  and  posterior  urethral, 
as  to  course  acute,  subacute  and  chronic,  as  to  distribution  local  and 
systemic  and  as  to  significance,  minor  and  major.  The  complications 
of  the  anterior  and  posterior  urethra  must  be  separated  because  of 
indi\iduality  in  anatomical  relations  and  pathological  types  and 
under  each  the  other  classifications  will  be  placed.    It  is  to  be  remem- 


TREATMENT  OF  THE  COMPLICATIONS  OF  URETflRITIS      511 

bered  that  most  acute  complications  become  chronic  and  that  there- 
after chronic  lesions  may  show  exacerbations  and  relapses  having  all 
the  features  of  new  acute  develoi)ments. 

Local  complications  are  divided  into  the  urogenital  group  comprising 
the  sexual  and  urinary  forms  and  the  systemic  group  coiitairn'rig  chiefly 
systemic  symptoms  without  true  invasion  of  extragenital  organs. 
Systemic  complications  catalogue  lesions  in  the  various  organs  of  the 
systems  attacked  exactly  as  stated  in  the  clinical  portion  of  the  subject. 

Minor  complications  are  of  the  foreskin  and  mucosa  alone  while  the 
major  complications  compromise  the  various  important  sexual  glands, 
the  urinary  system  and  the  general  system. 

General  Consideration. — General  consideration  implies  that  all  com- 
plications are  active  processes  and  express  rapidly  extending  involve- 
ment through  virulence  of  infection  or  the  transfer  of  lesions  from 
instrumentation  or  errors  on  the  part  of  the  patient.  They  all  require 
the  same  general  plan  of  treatment  especially  the  acute  complications 
while  the  chronic  foci  are  more  individualized. 

Preventive  and  abortive  measures  are  not  definite  in  general  terms 
beyond  the  value  of  full  comprehension  of  the  lesions  underlying  the 
symptoms,  good  management,  properly  applied  physical  measures, 
suitably  chosen  systemic  and  local  medicinal  measures,  avoidance  of 
offense  by  surgical  means,  and  above  all  abstinence  from  overtreatment. 
It  is  certain  that  proper  treatment  of  the  gonococcal  urethritis  not 
only  tends  to  limit  the  onset  of  complications  but  also  results  in  a 
less  severe  course,  when  they  do  occur.  Due  obedience  to  these  prin- 
ciples tends  to  prevention  while  abortive  treatment  is  in  the  nature  of 
things  not  possible  in  the  majority  of  the  complications. 

Treatment  of  Complications  of  Anterior  Gonococcal  Urethritis. 

Urogenital  Group. — Sexual  forms  embrace  the  minor  complications 
— phimosis,  paraphimosis,  balanitis,  posthitis  and  balanoposthitis, 
lymphangeitis  and  Ijonphadenitis,  littritis  and  folliculitis  in  either  acute 
or  clironic  forms  and  also  the  major  complication  co^\'peritis  in  its 
acute  or  chronic  stage  without  or  with  occlusion.  Urinarj'  forms  do 
not  occiu'  in  the  anterior  urethra  and  likewise  there  is  no  systemic 
group  m  the  strict  sense. 

Extraurogenital  or  Systemic  Group. — Significance. — In  general  all 
are  relatively  more  rare  than  the  urogenital  forms  and  almost  all 
depend  on  systemic  mvasion  except  when  direct  contact  of  pus  is 
obvious,  as  in  the  mucosa  of  the  mouth,  rectimi  and  eye.  In  their 
relation  to  systemic  invasion,  therefore,  they  are  all  very  important. 

Prophylaxis  is  directly  concerned  with  early  care  against  the  transfer 
of  the  pus  to  other  surfaces  embodied  m  the  asepsis  and  antisepsis 
of  the  standard  hygiene  already  described.  Indirectly  skillful  manage- 
ment and  treatment  of  the  initial  lesions  avoid  the  complications  and 
the  absorption  of  their  toxins  and  become  preventive.  Abortive 
measures  cannot  be  assigned  except  in  accessible  surfaces  such  as  the 


512  GENERAL  PRINCIPLES  OF  TREATMENT 

mouth,  rectum  autl  eye,  which  should  he  steriUzeil  at  the  foremost 
sjTiiptom  of  suspected  infection. 

General  curative  treatment  is  best  in  conservative  and  expectant 
forms  anil  nnist  reach  the  original  focus  of  infection  and  absorption, 
otherwise  failure  will  follow  treatment  of  the  systemic  comi)lication. 
The  best  exa-mple  of  this  is  persistence  of  arthritis  imtil  the  causal 
seminal  vesiculitis  or  prostatitis  is  relieved.  Based  on  exact  diagnosis 
of  the  lesions  all  the  usual  elements  of  management,  ])hysical  measures, 
metlicinal  means  and  surgical  procedures  ap})ly  as  previously  stated. 

SEROTHERAPY  OR  ORRHOTHERAPY. 

Opsonic  Index. — Basis. — ()rrhotherap>'  rests  on  the  sanu^  ])rinciples 
as  those  ah\'ad\'  stated  under  orrhodiagnosis  for  inmumity  and  ana- 
phylaxis and  will  not  be  rejieated.  As  previously  shoAMi  opsonins  are 
antibodies  which  act  on  the  bacteria  in  an  unknown  way  and  which 
result  in  the  destruction  of  the  infecting  organisms  so  that  the  white 
blood  cells  are  more  active  in  their  phagocytosis. 

Phagocxtic  count  is  the  endeavor  to  estimate  the  number  of 
organisms  destroyed  by  the  wdiite  blood  cells  and  is  made  by  taking 
the  blood  sermn,  white  blood-cells  and  bacteria,  mixing  them  together, 
incubating  them  for  a  definite  time  and  then  preparing  smears.  Differ- 
ential stains  are  then  made  and  the  numbers  of  bacteria  within  the 
bodies  of  the  white  blood-cells  in  many  microscopic  fields  are  averaged 
to  show  the  efficiency  of  the  phagocytosis  in  terms  of  the  ratio  between 
the  number  of  bacteria  Avithin  the  cells  and  that  of  the  cells  themselves. 

Opsonic  index  is  the  ratio  between  the  phagocytic  counts  in  disease 
and  in  health  and  was  regarded  by  ^Yright  of  London  as  a  mathematical 
expression  for  the  resistance  of  the  patient  to  the  disease.  He 
endeavored  to'  lay  down  the  following  broad  principles  as  applied  to 
this  subject. 

1.  Phagocytic  count  is  low  during  infection  and  high  during  health. 

2.  The  ratio  between  these  two  counts  or  the  opsonic  index  is  specific 
in  each  disease. 

3.  The  opsonic  index  is  a  measure  of  resistance  of  the  patient  to  the 
specific  disease. 

4.  The  opsonic  index  is  a  diagnostic  aid  because  specific,  in  being 
low  during  infection  with  a  given  disease,  but  remaining  high  at  the 
.same  time  for  other  diseases. 

5.  Immunity  therefore  raises  anaphylaxis,  lowers  the  oi)sonic  index. 
iNlany   of    these    teachings    have    been  abandoned   as  technically 

difficult  and  as  clinically  uncertain  but  the  broad  principles  remain 
accepted.  Clinical  data  are  therefore  naturally  regarded  as  decisive 
in  orrhotherapy  and  much  more  convenient  than  these  difficult  pro- 
cedures. 

Negative  and  Positive  Phase  of  Opsonic  Index. — The  administration  of 
bacterin  or  other  bacterial  product,  like  infection  with  the  disease 
itself,  lowers  the  opsonic  index  for  a  few  days.    This  action  is  techni- 


SEROTHKIlA  I'Y  Oli  OliltllOTII h:iiA  I'Y  F)  1  '4 

cally  called  the  ''negative  phase,"  persists  for  a})()ut  three  days  and  is 
slowly  followed  by  an  increase  in  the  index  during  the  next  succeeding 
days  to  a  limit  above  the  normal  and  known  as  the  "positive  phase." 
Additional  dose  of  the  bacterin  or  vaccine  during  the  negative  phase  is, 
therefore,  dangerous,  so  that  subsequent  inoculations  in  the  production 
of  active  immunity  should  occur  du:'ing  the  positive  phase.  These 
facts  determine  the  policy  of  administering  immunizing  doses  every 
five,  six  or  seven  days  in  accordance  with  the  form  of  bacterial  product 
used,  the  nature  of  the  germ  and  the  reaction  of  the  patient  to  previous 
injections. 

Active  Immunity.— Production  of  Active  Immunity. — Inoculation  may 
be  performed  in  man  and  in  animals  for  immunization  with  active 
bacteria,  inactive  or  dead  bacteria  and  bacterial  products  or  extracts. 
Active  bacteria  in  full  potency  are  never  used  in  man  but  are  reserved 
for  animal  experimentation  only.  In  man,  therefore,  only  attentuated 
or  modified  bacteria  are  applicable  and  the  best  examples  are,  of  the 
former,  inoculation  against  rabies,  and,  of  the  latter,  vaccination 
against  smallpox.  On  the  other  hand,  immunization  by  dead  bacteria 
is  the  rule  in  man  and  in  preference  the  same  strain  is  used  as  that 
found  in  specimens  of  exudate  and  pus  taken  from  the  patient.  In 
this  manner  are  produced  autogenous  bacterins  or  vaccines  which  in 
most  subjects  seem  to  have  a  greater  valence  for  inducing  immunity 
than  do  heterogeneous  or  stock  bacterins  or  vaccines  of  organisms  of  the 
same  type  secured  from  laboratories. 

Gonococcal  Bacterin  or  Vaccine. — In  gonococcal  infection  the  diflB- 
culty  of  isolation  of  the  individual  strain  is  doubled  by  the  large 
number  of  strains  and  by  the  great  uncertainties  of  culturing  the  gono- 
coccus.  In  this  disease,  therefore,  it  is  often  unavoidable  that  stock 
bacterin  shall  be  used,  but  good  results  are  obtained  if  the  product  is 
from  a  first-class  laboratory  where  details  of  standardization  are 
reliable.  In  no  event  can  the  practitioner  himself  prepare  these  pro- 
ducts for  the  same  reasons  as  were  set  forth  briefly  under  the  subject 
of  Complement  Fixation  Test  on  page  476.  It  is  necessary  to  order 
the  laboratory  doses  of  low  strength  first  and  from  these  advance  to 
concentrated  strength;  for  example,  50  million  in  1  c.c.  at  first,  gradu- 
ally increased  to  500  million  in  1  c.c. 

There  are  two  forms  of  bacterin  prepared  from  gonococcal  cultures: 
one  containing  the  gonococcus  alone  and  the  other,  called  combined 
bacterin,  containing  the  gonococcus  and  the  staphylococcus.  The 
preparation  of  gonococcal  bacterin  is  the  same  as  that  of  all  similar 
products,  from  cultures  whose  bacteriologic  and  physiologic  characters 
are  as  carefully  measured  as  possible,  and  then  inacti^'ated.  The 
strength  of  such  bacterin  is  in  millions  of  dead  bacteria  in  each  cubic 
centimeter  and  it  is  convenient  to  employ  those  products  which  are 
marketed  in  a  single  dose  container,  or  in  hospital  practice  in  larger 
containers  from  which  suitable  doses  are  taken  by  plunging  the  needle 
through  the  rubber  cap  of  the  bottle.  The  administration  is  either 
subcutaneous  or  intramuscular  and  the  initial  dose  is  100,000,000  or 
33 


514  GENERAL  PRINCIPLES  OF  TREATMENT 

less  slowly  increasing  to  from  300,000,000  to  500,000,000  every  two 
to  tliree  days — according  to  the  disappearance  of  the  negative  phase. 
The  preparation  of  gonococcal  combined  bacterin  is  the  same  with  the 
addition  of  cultures  of  tlie  Sta])hylococcus  albus,  citreus  and  aureus, 
so  that  there  are  500,000,000  dead  gonococci  and  400,000,000  dead 
staphylococci  in  each  cubic  centimeter  with  0.2  })er  cent,  of  trikresol 
as  preservative.  The  administration  is  subcutaneous  for  the  first 
dose  and  may  thereafter  be  intramuscular  if  the  local  reaction  has  not 
been  severe  and  the  dose  begins  with  from  0.2  to  0.5  c.c.  and  slowly 
ascends  according  to  the  activity  of  the  disease  and  the  condition  and 
reaction  of  the  patient,  such  as  headache,  malaise  and  feverislmess 
which  mark  the  negative  phase.  Subsequent  doses  are  given  from  five 
to  eight  days  apart  thereafter  or,  if  the  reaction  has  not  been  marked, 
at  shorter  intervals. 

Technic  of  Inoculation. — The  hands  of  the  surgeon,  the  skin  of  the 
patient  and  the  needle  and  syringe  are  all  fully  sterilized.  The  best 
needle  has  a  metal  mounted  glass  barrel  of  1  c.c.  capacity,  an  expandmg 
"asbestos  packed  plunger  on  a  hea\y  piston  marked  in  tenths  of  1  c.c. 
and  siu-mounted  Avith  a  large  head  for  standmg  the  syringe  upright. 
The  injections  are  made  subcutaneously,  as  a  rule,  or  intramuscularly, 
as  the  exception,  and  the  dose  may  be  as  low  as  2  or  3  million  and  as 
high  as  300  to  500  million.  Repetition  of  dose  is  not  less  than  every 
three  days  and  longer  if  the  patient  is  disturbed.  The  three-day 
interval  may  be  used  in  the  smaller  doses  and  the  five-  or  seven-day 
interval  in  the  larger  doses.  All  these  points  rest  on  the  form  of  infec- 
tion, the  condition  of  the  patient,  the  reaction  to  each  injection  and  the 
control  of  the  s}Tnptoms.  The  selection  of  bacterin  is  important  and 
rests  on  exact  bacteriologic  diagnosis.  Autogenous  gonococcal  bacterin 
is  difficult  to  secure  as  already  stated  so  that  standard  stock  products 
are  the  rule,  and  fm-thermore,  a  mixed  vaccine  in  which  the  gonococcus 
and  one  or  more  of  the  pyogenic  organisms  are  combined  may  be  indi- 
cated because  in  many  lesions  the  gonococcus  alone  is  not  present, 
particularly  in  rheimiatism,  so  that  a  pure  gonococcal  bacterin  will  fail 
through  omission  of  the  associated  organisms. 

Combined  Bacterin  of  Van  Cott^  and  other  mixed  bacterins  made  of 
much  the  same  organisms  and  having  similar  therapeutic  indications 
and  values  deserve  attention.  Van  Cott  says:  "The  theory  which  led 
to  this  combination  was,  that  it  would  be  valuable  in  many  cases  where 
time  was  an  element  and  autogenous  vaccines  impracticable  and  that 
if  clinical  experience  of  its  use  demonstrated  that  it  could  be  safely 
used  by  the  general  practitioner  with  reasonable  expectation  of  desired 
results  such  a  polyvalent  vaccine  would  find  a  wide  sphere  of  useful- 
ness." When  facilities  are  not  at  hand  for  exact  bacteriologic  diagnosis, 
or  when  for  technical  difficulties  the  diagnosis  is  uncertain  then  any 
of  these  mLxed  bacterins  is  available.  They  are  all  more  or  less  com- 
posed of  the  common  pus-producing  organisms,  excepting  the  gono- 

1  New  York  State  Jour.  Med.,  July,  1911. 


SEROTHERAPY  OR  ORRIIOTJIERAPY  515 

coccus,  and  the  so-called  pyogenic  Kroiip  corni)risinK  the  streptoeocci 
and  the  staphylococci  are  omitted  from  none.  Difl'ereiit  laboratories 
prefer  to  add  to  these  the  Bacillus  coli  communis,  the  pneumococcus 
and  the  bacillus  of  diphtheria  and  others  in  various  combinations  but 
the  formula  of  Van  Cott  has  the  preference.  It  consists  of  the  following 
organisms : 

'  Streptococcus  longus 50,000,000 

(aureus  "j 
"^^^l^  .500,000,000 

(^  citreus  J 
Bacillus  coli  communis 200,000,000 


Total 75O,0C0,0OfJ 

Bacterial  Products. — Filtrates  and  extracts  (phylacogens,  Schafer'j 
are  also  of  value  in  the  induction  of  immunity  and  in  orrhotherapy.  As 
the  term  indicates,  a  filtrate  is  a  culture  from  which  the  organisms  have 
been  removed  by  filtration  and  more  or  less  loosely  the  term  extract 
is  also  used,  because  such  filtrate  contains  products  of  the  organisms 
rather  than  the  inactive  organisms,  as  w^ell  as  such  products.  One  of  the 
most  typical  and  yet  not  of  the  most  satisfactory  application  of  such 
filtrate  is  that  seen  in  tuberculosis,  w^hich  may  be  discussed-  in  this 
chapter  on  account  of  the  lesions  of  this  disease  and  their  treatment 
described  in  the  sections  on  Tuberculosis  of  the  Bladder  and  Kidneys, 
pages  767  and  881.     Filtrates  are  probably  less  potent  than  bacterins. 

Gonococcal  phylacogen  or  filtrate  is  a  sterile  aqueous  solution  of 
bacterial  derivatives  from  cultures  of  the  gonococcus  in  rather  large 
proportion  and  in  less  proportion  of  other  pathogenic  bacteria,  especi- 
ally the  Streptococcus  rheumaticus  (Pojiiton  and  Paine),  Streptococcus 
pyogenes,  Streptococcus  erysipelatis,  Staphylococcus  pyogenes.  Bacillus 
pyocyaneus,  Bacillus  coli  communis.  Bacillus  diphtheri£e,  and  Diplo- 
coccus  pneiunonise.  Numerous  strains  of  the  several  organisms  from  a 
variety  of  sources  are  employed.  The  basis  of  treatment  rests  on  the 
facts  that  long-standing  gonococcal  infections  are  not  simple  with  the 
gonococcus  alone  but  complex  with  the  presence  of  many  organisms 
and  that  the  latter  may  persist  by  themselves  after  the  gonococcus 
has  disappeared.  The  organisms  themselves  are  filtered  out  of  the 
preparation  which  is  then  carefully  standardized  as  to  absolute  sterility 
and  as  to  tolerance  of  test  animals  for  it.  The  indications  are  chiefly 
the  complications  and  sequels  of  chronic  gonococcal  m-etlu'itis  as  it  is 
of  less  or  little  service  in  the  acute  disease.  In  the  male,  prostatitis, 
seminal  vesiculitis,  epididymitis  and  orchitis  and  m  the  female,  vaginitis, 
cervicitis,  endometritis,  salpingitis  and  ovaritis  and  in  both  sexes 
cystitis,  ureteritis  and  pyelitis  and  perhaps  most  important  of  all 
arthritis  are  benefited  by  its  use — always  combined  with  standard 
methods  of  treatment  and  never  alone.  The  administration  is  either 
subcutaneous,    intramuscular    or    intra^'enous.      The    former    should 

1  Therap.  Gaz.,  AprU  15,  1911. 


516  GEXERAL  I'RlXCirLKS  OF  Th'EATMEXT 

always  bo  the  hririnniiiir  of  tlio  tivatiiuMit  as  a  (lotenn'iiiaiit  of  tlu> 
patient's  susceptil)ilit>-  and  lionefit  and  the  lattrr  is  reserved  for  cases 
in  whieh  tlie  former  may  not  be  snftieiently  active.  Tlie  subentaneons 
dose  beirins  witli  1  e.e.  and  ascends  to  .">  or  ]()  c.c.  nnless  the  patient  is 
debilitated,  when  half  the  nsual  (piantity  is  advised.  The  activity  of 
the  disease,  the  inflnence  of  this  treatment  ni)on  it  and  the  general 
progress  of  the  case  determine  the  amonnt  of  dose  and  its  freqnency, 
which  is  nsually  every  two  to  three  days.  The  intraxencnis  dose  is 
from  O.llV)  to  0.25  c.c.  at  first,  followed  by  twice  these  qnantitics  at 
second  and  subseqnent  doses  until  the  fourth  dose  is  1  c.c.  Knowledge 
of  the  patient's  susceptibility  to  phylacogen  by  the  subcutaneous  route 
is  a  i)reluiiinary  of  intravenous  administration  and  dilution  of  the  prep- 
aration with  warm  normal  salt  solution  is  ad\antageous. 

The  technic  of  i)hylacogen  administration  is  the  same  as  that 
described  for  bacterins  and  vaccines  in  its  preliminaries  for  the  surgeon, 
attendants,  instruments  and  patient.  The  site  of  injection  is  subcu- 
taneous, as  a  rule,  and  intranniscular  or  intravenous,  as  exce])tions, 
and  the  aim  is  to  avoid  the  negative  phase  and  to  select  the  positive 
phase.  The  internals  of  repetition  of  dose  are  determined  according 
to  the  condition  of  the  patient,  the  reaction,  the  persistence  of  the 
negative  phase  aiul  the  incidence  of  the  positive  phase,  from  clinical 
signs  rather  than  from  oi)sonic  index.  The  size  of  dose  is  from  5  to 
10  c.c.  for  the  gonococcal  filtrate  and  from  1  to  5  c.c.  for  the  mixed 
filtrate,  with  gradual  ascent  between  these  two  limits.  Intravenous 
doses  are  a  foiu-th  or  a  half  of  the  subcutaneous  quantity.  A  mixed 
infection  vaccine  or  filtrate  obtained  from  pr()])er  culture,  standardiza- 
tion and  mixture  is  secured  from  the  Sta])hylococcus  aureus,  albus  and 
citreus,  Streptococcus  pyogenes,  pyocyaneus  and  erysijjelatis,  pneumo- 
coccus  and  Bacillus  coli  communis  and  typhosus.  After  proper  culture 
in  suitable  media  the  mixture  is  made  and  standardized  as  to  strength 
and  the  filtrate  jwepared  for  dose  of  standard  degree.  In  a  certain 
sense  it  is  a  "gunshot  mixture,"  but  has  great  \alue  in  infections  whose 
precise  bacteriologic  features  cannot  be  determined  and  whose  originat- 
ing organism  may  haA'c  disappeared;  as  examples,  certain  lesions  in 
tuberculosis  and  in  chronic  gonococcal  comjilications  are  mentioned. 

Reaction  and  Dangers  of  Immunizing  Doses  of  bacterin  and  phylacogen 
are  seen  as  local  and  systemic  manifestations.  On  the  whole  in  the 
former,  they  are  somewhat  more  active  than  in  the  latter.  The  local 
reactions  are  a  swelling  rarely  advancing  to  infiltration,  redness  some- 
times with  edema,  and  tenderness  accompanied  infrccjucntly  by  actual 
pain.  They  disap])car  in  from  two  to  seven  days  and  rarely  require 
local  sedative  apj^lication.  The  jnu-pose  of  strict  asepsis  and  antisepsis 
is  to  eliminate  the  possibility  of  incidental  infection  and  to  make  the 
local  reaction  purely  that  of  the  inoculation  itself.  The  systemic 
reaction  really  indicates  the  negative  i)hase  and  manifests  itself  in  a 
chilliness  or  chill,  feverishness  or  fever,  anorexia  or  nausea  and  rarely 
vomiting  and  a  feeling  of  "being  out  of  sorts"  and  irritability  with 
sometimes  actual  malaise  and  depression.    The  more  severe  symptoms 


SEROTHERAPY  OR  ORRIIOTIIERAI'Y  517 

are  the  exceptions.  Within  twcnty-fonr  hours,  as  a  rule,  the  patif;tit 
feels  well  again  and  nsuiilly  re])orts  pronij)t  ons(!t  of  these  syM)])toins 
within  an  hour  or  two  of  the  dose  but  delayed  onset  sometimes  occurs. 
If  the  administration  is  made  in  the  late  evening  office  hour  and  the 
patient  sent  home  to  bed,  systemic  reaction  may  not  be  perceived  by 
him.  The  dangers  of  intravenous  inoculation  with  mixed  phylacogens 
or  filtrates  are  real  in  their  sudden  severe  reaction  and  sometimes  fatal 
termination.  The  systemic  symptoms  are  much  more  marked  and  the 
result  is  assumed  to  be  more  prompt  than  in  either  the  subcutaneous 
or  intramuscular  method  although  it  is  difficult  to  see  how  a  process  so 
slow  as  immunity  can  be  materially  hastened.  The  te(;hnic  is  the;  same 
as  that  employed  for  subcutaneous  and  intramuscular  inoculation  with 
extraordinary  precautions  for  asepsis  and  antisepsis  in  order  to  avoid 
extraneous  infection.  A  fine  hypodermic  needle  only  is  employed 
with  clear  lumen  and  unless  the  blood  flow  is  a  prompt  free  dripping, 
the  needle  must  be  proved  to  be  in  the  vein  by  aspiration.  After  this 
the  injection  syringe  is  applied  to  it  and  the  dose  given,  whose  size  is 
reduced  to  half  or  less  than  half  the  usual  quantity  (0.25  or  0.50  cubic 
centimeters).  The  injection  must  occupy  several  minutes  so  that  a 
mass  dose  thrown  into  the  blood  is  avoided.  The  dangers  and  dis- 
advantages of  this  method  and  its  results  which  up  to  the  present  are 
too  little  understood  make  it  inadvisable  for  ordinary  use. 

Passive  Immunity. — Production  of  passive  immunity  is  efficient  in 
protection  against  disease  and  differs  from  active  immunity  in  not 
being  natural  in  the  sense  that  the  subject  produces  it  and  in  being 
artificial  in  the  sense  that  the  injected  material  contains  the  protective 
antibodies.  The  basis  is,  therefore,  the  injection  into  the  animal  to  be 
immunized  of  a  proper  dose  or  niunber  of  doses  of  the  sermn  of  an 
animal  fully  immunized.  It  is  available  in  patients  who  cannot  pro- 
duce natural  immunity  at  all  or  with  sufficient  promptness  or  who  are 
already  infected  with  germs  temporarily  inert  and  therefore  in  need  of 
protection  at  once.  The  best  example  of  passive  immunity  is  shown  by 
diphtheritic  antitoxin,  which  will  protect  the  patient  already  infected 
and  showing  symptoms  often  against  further  progress  of  his  disease  and 
will  immunize  members  of  his  family  against  progress  to  the  active 
stages  of  an  infection  as  yet  inactive  in  the  nose  and  throat.  The  results 
are  ideally  in  all  diseases  the  same  as  those  in  diphtheria  but  are  not 
practically  reached  in  many  of  them;  nevertheless  in  gonococcal  infec- 
tions the  results  aimed  at  are  the  same. 

Antigonococcic  Serum. — Torrey^  was  the  first  to  prepare  and  experi- 
ment with  gonococcal  serum  originally  from  the  blood  of  rams  but  lately 
from  the  blood  of  horses,  which  produces  less  untoward  reaction.  The 
animals  are  thoroughly  immunized  with  gradually  increasing  dose  of 
dead  and  living  cultures  of  virulent  gonococci,  occasionally  combined 
with  gonococcic  endotoxin.  The  collection  of  the  blood,  the  separation 
of  the  serum  and  its  preparation  for  market  are  the  same  as  now 

1  Jour.  Am.  Med.  Assn.,  September  14,  1907. 


518  GENERAL  PRINCIPLES  OF  TREATMENT 

t'aniiliar  in  antiiliphthoritir  aiul  other  siM'unis.  Decomposition  is  pre- 
vented by  0.4  per  cent,  of  trikresol,  each  stock  of  serum  is  tested  in 
bulk  baoteriolofjically  and  standardized  i)hysiologically  and  then  dis- 
tributed to  bulbs  which  are  heriuetieally  sealed.  Absolute  standard 
cannot  be  adopted  for  serums  but  the  activity  of  each  k)t  is  determined 
by  specific  innnunity  reactions,  such  as  the  complement  fixation  test. 
The  indications  of  its  use  are  regarded  as:  (1)  direct  exten>ion  into 
organs  like  the  ei)ididymis,  testicle,  prostate,  seminal  vesicles,  fallopian 
tube^,  bladiler  and  kidneys  all  from  an  active  primary  focus,  and  (2) 
entrance  of  the  organisms  or  their  toxins  into  the  bloodstream  directly 
or  tlirough  the  lymphatics  indirectly,  inducing  such  lesions  as  arthritis, 
iritio,  endocarditis,  i)leuritis  and  meningitis.  On  the  whole  the  serum 
is  less  efficient  than  the  bacterin  for  reasons  not  fully  understood  but 
probai)ly  resident  in  cultural  ])eculiarities  of  the  gonococcus.  Adminis- 
tration is  by  injection  into  the  thighs,  al)domen,  buttocks  or  breasts 
after  suitable  preparation  of  the  skin.  Either  the  subcutaneous  or  the 
intramuscular  route  may  be  employed  and  always  at  slow  rate  in  order 
to  a\oid  ])ain  and  the  tendency  to  severe  local  reaction.  The  doses 
connnonly  employed  begin  with  2  c.c.  repeated  every  one  to  four  days 
according  to  indications  from  the  condition  of  the  disease,  the  health 
and  reaction  of  the  patient  to  previous  injections.  The  limit  of  dose  is 
usually  10  c.c.  which  is  reached  by  gradual  increase  from  the  initial 
dose.  Corbus,^  among  other  obserx'ers,  recommends  larger  doses,  12  to 
15  c.c.  daily  for  three  days  up  to  a  total  of  30  or  45  c.c.  The  adminis- 
tration of  serum  does  not  exclude  other  measures  of  treatment  and 
should  in  fact  always  be  combined  with  them. 

Gonococcal  passive  immunity  is  attempted  and  may  be  partially 
established  in  the  acute  stage  having  general  or  systemic  absorption. 
The  gonococcal  serum  is  injected  after  having  been  secured  from  an 
immunized  anunal  in  slowly  ascending  doses  at  regular  and  rather  short 
intervals  beginning  with  2  c.c,  and  ending  with  10  c.?.,  every  two  or 
three  days.  A  longer  period  of  rest  between  administrations  is  said 
to  invite  anaphylaxis;  in  other  words,  the  positi^'e  phase  must  be 
carefully  obserN'ed  for  the  administration.  Gonococcal  serobacterins, 
by  which  is  meant  a  combination  or  mixture  of  the  serum  and  bacterin, 
may  be  used  in  in3tituting  passi^'e  immunity  for  the  first  few  days. 
The  reaction  of  the  serum  is  believed  to  prepare  the  w^ay  for  the  influ- 
ence of  the  bacterin,  but  may  not  be  continued  for  longer  than  the  first 
few  administrations,  two  or  three,  and  after  this  should  be  followed 
by  the  bacterin  alone  after  the  usual  manner. 

Indications  of  Gonococcal  Orrhodiagnosis ;  Orrhotherapy  and 
Immunization. — The  general  princii^les,  as  already  indicated,  apply  to 
chronic  rather  than  acute  stages,  to  persistent  rather  than  recent 
infections,  to  complicated  rather  than  uncomplicated  cases  and  to 
systemic  rather  than  local  s.>anptoms.  The  essentials  or  preliminaries 
are  careful  bacteriological  diagnosis  of  the  infection  by  the  gonococcus 

»  Jour.  Am.  Med.  Assn.,  May  9,  1914. 


SEROTHERAPY  OR  ORRHOTHERAPY  519 

and  its  associates  and  in  this  step  cultures  cannot  be  omitted.  Tiie 
gonococcal  complement  fixation  test  must  be  performed  and,  if  posi- 
tive, will  in  association  with  the  bacteriologic  decision  become  a  guide 
to  this  kind  of  treatment  and  to  the  choice  between  serum  and  bacterin 
and  phylacogen  or  a  combination  of  them.  Emphasis  is  laid  on  the 
fact  that  these  laboratory  products  cannot  be  relied  on  alone  in  the 
treatment  of  these  infections  and  that  they  oan  only  be  combined  with 
recognized  medical  and  surgical  measures,  such  as  are  described  in  the 
special  section  devotid  to  each  subject. 

In  general  it  should  be  remembered  that  in  the  acute  stage  of  gono- 
coccal urethritis  in  either  sex  the  lesions  are  on  the  surface  of  the  mucosa 
and,  therefore,  on  the  surface  of  the  body  in  a  strict  sense  although  that 
surface  is  within  a  canal.  This  peculiarity  distinguishes  the  infection 
from  those  which  rapidly  invade  the  bloodstream  and  the  lymphstream 
and  thereafter  the  body  as  a  whole  and  renders  the  former  somewhat 
less  readily  amenable  to  orrhodiagnosis  and  orrhotherapy  than  the 
latter.  In  gonococcal  infections  without  complications  of  the  anterior 
urethra,  systemic  absorption  and  symptoms  are  extremely  rare  and  such 
as  exist  probably  represent  a  temporary  disturbance  of  the  body  such 
as  is  seen  in  all  disease  and  not  a  general  invasion.  In  posterior  acute 
urethritis  absorption  is  more  apt  to  be  a  real  factor  even  if  there  are  no 
complications  and  when  the  latter  supervene  the  element  of  systemic 
disturbance  becomes  important  in  both  the  acute  and  chronic  forms  of 
posterior  urethritis. 

Indications  of  gonococcal  orrhotherapy  may  be  classified  as  follows: 

1.  Acute  complications,  in  both  anterior  and  posterior  disease, 
having  severe  local  and  systemic  symptoms,  as  seen  in  the  testis, 
epididymis,  prostate  in  the  male,  tubes,  ovariei  and  uterus  in  the 
female  and  bladder,  ureters  and  kidneys  in  both  sexes. 

2.  Chronic  complications,  having  the  same  location  and  distribution 
as  those  just  given  for  acute  foci,  and  showing  severe  absorptive  symp- 
toms which  are  much  more  common  than  in  the  acute  periods. 

3.  Systemic  invasions,  as  exemplified  in  infarcts  or  metastases  in  the 
synovia  of  joints,  bursse  and  tendons  and  occasionally  the  pericardium 
and  the  endocardium.  In  this  class  may  be  placed  peritoneal  involve- 
ment in  women,  because  of  the  identity  of  the  membrane  affected  and 
not  because  peritonitis  is  metastatic. 

4.  Systemic  absorption  and  toxemia  with  intense  acute  symptoms, 
usually  from  mixed  infection  and  due  to  spread  of  the  disease  through- 
out the  system. 

Gonococcal  Acute  and  Chronic  Urethritis  without  Complications. — In 
eaily  acute  lesions,  as  already  shown  on  pages  24  to  27,  the  gonococcus 
alone  is  the  exciting  element,  whereas  in  the  cln'onic  lesions,  also  as  pre- 
viously described  on  page  265,  the  gonococcus  is  allied  with  the  pyogenic 
organisms.  The  well-known  laboratory  peculiarities  of  the  gonococcus 
and  its  superficial  presence  in  the  mucosa  away  from  the  influence  of  the 
bloodstreams  and  lymphstreams  tend  to  make  failures  in  orrhotherapy 
frequent,  but  in  chronic  lesions,  where  the  penetration  has  been  greater, 


520  GEXERAL  I'Id.WIPLES  OF  TREATMEXT 

successes  are  more  iiimicrous,  especially  it'  the  niixeil  bacterin  or  filtrate 
is  used  associated  witii  the  jj:onococcal  i)rei)arations  or  subsequent  to 
them.  The  gonococciis  is  aj^t  to  die  within  about  three  years,  accord- 
ing to  ob..ervations  by  Keyes,'  but  disease  in  the  host  may  persist  and 
infection  of  the  opposite  party  in  wedlock  may  occur,  arising  from 
the  l)re^ence  of  the  pyogenic  organisms  alone.  On  this  fact  rests  the 
obser\ation  that  in  old  urethritis  the  mixed  bacterins  and  hltrates  are 
alone  worth  while,  in  cases  wherein  the  gonococcus  cannot  be  isolated 
or  demonstrated. 

Complications  of  Gonococcal  Acute  Urethritis,  whether  recent  or 
relai)sing.  all  show  slight  systemic  absor])tion  in  a^■erage  cases,  but  in 
inten.se  cases  this  element  may  be  greater  and  yet  ne\er  equal  those 
seen  in  chronic  lesions,  no  matter  whether  in  either  case  the  infection 
is  piu'c  or  mixed.  Directly  proportional  with  the  degree  of  systemic 
reaction  is  the  advisability  of  applying  the  bacterin  or  serum  treat- 
ment, which  must  never  be  begun  without  full  bacteriologic  and  hema- 
tologic investigation.  In  general,  where  the  gonococcus  alone  is  present 
in  the  case,  gonococcal  bacterin,  gonococcal  serum  and  gonococcal 
])hylacogen  may  be  used,  separately,  serially  or  combined.  The  serum 
is  probably  the  least  serviceable  and  may  be  added  to  the  bacterin  for 
only  the  first  few  administrations.  Autogenous  bacterin  and  ])hyla- 
cogen  should  be  fir.st  choice  and  may  be  followed  by  stock  products  if 
their  influence  seems  deficient.  Where  the  gonococcus  is  associated 
with  pyogenic  allies,  bacterin  and  phylacogen  derived  from  the  gono- 
coccus and  the  other  organism  may  be  used,  provided  the  gonococcus  is 
still  present  in  ob^■ious  numbers,  but  if  absent  the  mixed  bacterin  of 
^'an  Cott  is  ad^•isable.  Again  the  preference  is  for  autogenous  and 
not  for  stock  preparations,  except  Van  Cott's  bacteria,  which  is  essen- 
tially a  laboratory  product.  To  simi  up,  therefore,  gonococci  alone  in 
the  infection  reciuire  theu*  ow-n  laboratory  products,  but  as  they  dis- 
appear from  the  patient,  they  should  also  be  eliminated  from  the  treat- 
ment and  only  those  organisms  used  ^^'hich  are  present.  Pus  accumu- 
lations into  abscesses  indicate  surgical  treatment  and  contraindicate 
orrhotherapy.  The  doses  of  these  products  have  already  been  given 
and  may  be  remembered  as  for  the  stronger  preparations  of  serum  and 
phylacogen  as  5  c.c,  as  the  largest  dose  and  for  the  less  potent  i)roducts 
as  10  c.c,  as  the  largest  dose,  while  initial  administrations  are  portions 
of  these  limits  determined  by  the  activity  of  the  disease  and  the  con- 
dition of  the  patient.  The  inter\-al  of  dose  is  two  or  three  days,  rather 
a  short  than  a  long  inter^■al  with  great  caution  for  the  negative  phase 
and  careful  observation  for  the  appearance  of  focalized  pus,  in  single  or 
multiple  abscesses. 

Complications  of  Gonococcal  Chronic  Urethritis. — Specimens  must  be 
carefully  studied  for  the  form  of  infection  present,  determining  the 
gonococcus  alone  or  its  associates.  Such  specimens  must  include 
discharge  in  the  form  of  i)us  or  shreds  or  scattered  organisms  in  the 

1  Am.  .Jour.  Med.  Sc,  1912,  cxliii,  107. 


SEROTHERAPY  OR  ORRIIOTIIERAPY  521 

urine,  and  elements  obtained  from  the  seven-glass  test  of  the  author 
after  careful  massage  of  the  prostate  and  seminal  vesicles  and  semen 
secured  in  a  condom.  Full  diagnosis  is  essential,  and  rests  on  physical 
examination  to  determine  the  parts  or  glands  affected,  on  bacteriology 
to  show  the  organisms  individually  or  collectively  present  in  the  infec- 
tion and  to  outline  the  results  of  previous  treatment  and  on  h(;matology 
to  indicate  the  complement  fixation  test.  Hie  decision  thus  rendered 
determines  the  application  of  other  treatment,  the  preparations  of 
autogenous  bacterins  and  filtrates  and  the  selection  of  the  product 
appropriate  for  the  case.  As  in  the  acute  infections,  just  stated,  gono- 
coccal bacterin,  phylacogen  and  serum  belong  to  the  infections  (jf  pure 
gonococcal  culture,  and  may  be  used  alone,  serially  or  combined,  as 
autogenous  or  stock  products.  The  mixed  cases,  however,  demand  a 
proper  combination  of  the  gonococcal  with  the  allied  infection  and 
those  in  which  the  gonococcus  cannot  be  determined  receive  the  mixed 
bacterin  of  Van  Cott.  The  doses  are  small  in  the  beginning,  slow  in 
their  ascent,  should  avoid  the  negative  phase  and  respect  only  the 
positive  phase  and  the  intervals  are  usually  three  days.  As  stated 
under  the  acute  complication  5  c.c.  is  the  limit  of  strength  for  the 
stronger  phylacogens  and  serums  and  twice  this  quantity  for  the  weaker. 
Initial  doses  must  remain  well  within  these  limits.  The  gonococcal 
bacterin  may  be  begun  with  about  25,000,000  and  increased  to  500,- 
000,000  if  well  borne  but  smaller  doses  are  the  rule,  repeated  every 
three  to  five  days  with  longer  intervals  between  the  increases  of  strength 
of  dose.  The  gonococcal  phylacogen  is  administered  in  from  5  to  10 
c.c.  doses  every  one  to  three  days  and  the  gonococcal  serum  in  from  2 
to  10  c.c.  every  three  days  for  a  few  times.  All  these  applications 
rest  on  the  condition  of  the  patient,  the  state  of  his  disease  and  his 
reaction  to  each  application. 

Gonococcal  metastases  or  infarcts  affect  chiefly  the  s^aiovial  mem- 
brane of  the  joints,  bursse  and  tendons  and  may  be  classed  under  the 
general  heading  of  gonococcal  rheumatism  which  may,  therefore,  be 
arthritic,  bursitic  or  myositic,  typically  or  variously  combined.  A 
most  important  detail  of  this  condition  is  treatment  of  the  seminal 
vesicles,  in  which  the  majority  of  these  cases  arise  as  the  focus  of 
absorption.  Other  methods  of  treating  joints,  bursae  and  muscles  are 
necessary  along  with  the  application  of  the  gonococcal  products, 
bacterins,  and  phylacogen  and  serum.  The  bacterins  are  the  most 
efficient  and  are  administered  in  exactly  the  method,  doses  and  pre- 
cautions described  under  Complications  of  Gonococcal  Chronic  Ure- 
thritis on  page  259.  The  frequency  with  w^hich  other  bacteria  occur  in 
association  with  the  gonococcus  in  all  these  cases  makes  it  essential  to 
use  either  the  combined  gonococcal  bacterin  or  the  mixed  bacterin  of 
Van  Cott. 

Gonococcal  toxemia  is  seen  sometimes  in  intense  acute  infection  but 
more  commonly  in  profound  and  mixed  chronic  complications.  It 
presents  the  condition  of  absorption  from  one  or  more  active  through 
chronic  foci  of  the  bacterial  products,  rarely  those  of  the  gonococcus 


522  GENERAL  PiaXCJPLES  OF  TREATMENT 

alone  but  more  frequently  those  of  this  organism  allied  Avith  numerous 
pyogenic  germs,  exactly  as  in  the  case  of  gonococcal  rheumatism,  with 
which  in  fact  toxemia  is  not  infre(iuently  associated.  The  presence  of 
fever  in  these  toxemias  and  other  profoimd  symptoms  of  more  or  less 
consistent  presence  during  the  attack  make  it  difficult  to  determine 
where  the  negati\e  phase  of  an  inoculation  ends  anil  where  the  ]iositive 
l)hasc  begins.  With  careful  obscrxation,  however,  bacterin  and  phyla- 
cogen  may  be  employed  in  very  small  doses  at  intervals  of  three  days 
or  more,  during  x\hich  careful  note  of  the  reaction  is  kept. 

Contraindications.  —  Contraindications  of  the  administration  of 
serum,  bacterin  and  ])hylacogen  are  adx'anced  circulatory  and  renal 
disease  and  general  debility,  so  far  as  selection  of  this  treatment  in 
general  is  concerned,  but  so  far  as  the  repetition  of  dose  is  considered 
the  presence  of  an}^  systemic  reaction  marks  the  negati\'e  phase  and 
forbids  a  subsequent  dose  until  it  has  subsided  and  imtil  the  positive 
])hase  is,  therefore,  established. 

By  wa>'  of  comparison  and  in  respect  for  the  great  importance  of 
urogenital  tuberculosis  a  few  words  on  its  immunization  are  in  order. 

Immunization  in  Tuberculosis. — The  disadvantages  of  immunization 
by  the  injection  of  tuberculin  or  emulsion  of  bacilli  are  as  follows: 
The  inoculations  must  be  continued  for  a  long  time  in  order  to  secure  a 
result — for  many  months  and  even  a  year  or  two.  The  presence  of 
mixed  infection  in  most  tuberculous  lesions  is  an  element  of  uncertainty 
and  may  require  a  mixed  bacterin,  as  discussed  in  succeeding  paragraphs. 
In  the  long  term  of  the  inoculations  the  influence  of  other  treatment 
cannot  be  disregarded,  such  as  hygienic  surroundings,  climate,  forced 
feeding,  tonics  and  the  like,  and  in  the  absence  of  such  management  of 
the  disease  the  inoculations  fail  absolutely,  as  they  also  do  when  an 
active  surgical  focus  of  tuberculosis  has  not  been  properly  interfered 
with.  These  facts  seem  to  indicate  that  injections  alone  cannot  be 
relied  on  and  that  they  will  make  no  headway  against  neglected  or 
improper  singical  or  medical  treatment  and  its  common  result  in  the  pro- 
gress of  the  disease.  The  accepted  preparations  are  in  descending  order 
of  potency:  (1)  emulsion  of  bacilli  (B.  E.)  and  (2)  new  tuberculin 
(T.  K.)  and  the  doses,  as  in  all  other  immunization,  aim  to  avoid  severe 
reaction,  much  depression  and  prolonged  negative  phase.  As  the 
bacillus  of  tuberculosis  is  one  of  the  most  toxic  it  follows  that  the 
initial  doses  must  be  very  small  and  the  ascent  in  quantity  very  gradual. 
The  emulsion  of  bacilli  is  much  more  potent  than  the  tuberculin  and 
the  initial  dose  is  commonly  TiTinrdd  of  a  milligram  administered  every 
three  to  seven  days  and  slowly  increasing.  The  new  tuberculin  is  given 
in  doses  of  from  4  ,nr(7  to  -  ;',-]y  of  a  milligram  and  the  increase  between 
these  limits  is  slow  and  judicious.  It  is  well  to  give  a  longer  rest  than 
the  common  interv^al  of  dose  between  each  change  in  the  strength  of 
dilution  used  and  to  insist  on  preserving  regularity  and  cooperation 
by  the  patient. 

Record  of  Immunizing  Doses. — ^I'he  importance  of  following  immuni- 
zation in  accordance  with  the  results  of  each  dose  makes  it  advisable 


SEROTHERAPY  OR  ORRIIOTIIERAPY 


523 


to  adopt  a  chart  or  record.  One  wliicli  the  author  has  found  of  great 
service  follows. 

In  the  left-hand  column  are  given  the  gross  doses  in  terms  of  tenths 
of  a  cubic  centimeter,  which  is  a  convenient  quantity  for  accurate 
measure  and  readily  provided  by  the  author's  syringe. 

In  the  second  colmun  are  set  forth  the  net  dose  in  milligrams,  which  in 
the  specimen  record  shown  begins  with  0.(!0001  and  ascends  to  0.00010. 
Such  a  series  of  doses  will  change  with  each  stronger  dilution  employed 
and  the  same  dose  may  be  repeated  several  times  according  to  indi- 
cation so  that  the  ascent  through  a  series  of  ten  doses  from  the  weakest 
to  the  strongest  dose  of  the  series  may  be  protracted  for  much  more 
than  one  month  as  shown  in  the  specimen  record. 

In  the  third  column  are  shown  the  dilution  of  bacillus  emulsion 
employed  which  will  change  with  each  such  dilution  selected.  In 
ordinary  experience  the  next  strength  would  be  1  in  1000. 

In  the  fourth  column  are  contained  the  quadrants  of  the  glutei 
employed  for  either  the  subcutaneous  or  the  intramuscular  injection 
as  described  in  a  contribution  by  the  writer^  on  the  subject  of  the 
treatment  of  syphilis. 

In  the  fifth  column  are  noted  the  doses  actually  given,  each  in  a 
separate  small  column  of  its  own  bearing  at  the  top  the  date  of  the 
visit,  whose  interval  in  the  specimen  record  is  every  three  days  but 
may  be  made  longer  according  to  indications.  By  turning  the  chart 
around  and  wTiting  in  these  date  columns,  as  shown  in  the  last  one, 
brief  notes  of  particular  features  may  be  kept. 

The  heading  of  the  chart  contains  the  name  and  the  suggested 
diagnosis. 


CHART    FOR   IMMUNIZING     DOSES    IN    TUBERCULOUS    AND    GONOCOCCAL 

INFECTION. 

Name 

Date  of  Treatment 


Gross 

dose  in 

c.c. 

Net  dose  in 

mg. 

Dilution 
B.  E.  1  in. 

Quadrants  of  the 
glutei  employed. 1 

Range  of  dose  0.00001  to  0.00010  mg. 

0.1 

.00001 

10,000 

Right  upper  3" 

0.1 

0.2 

.00002 

10,000 

Left  upper     3" 

0.2 

0.3 

.00003 

10,000 

Right  upper  5" 

0.3 

0.4 

.00004 

10,000 

Left  upper     5" 

0.4 

0.5 

.00005 

10,000 

Right  lower  1" 

0.5 

0.6 

.00006 

10,000 

Left  lower      1" 

0.6 

0.7 

.000G7 

10,000 

Right  lower  3" 

0.7 

0.8 

.00008 

10,000 

Left  lower     3" 

0.8 

0.9 

.00009 

10,000 

Right  lower  5" 

0.9 

1.0 

.00010 

10,000 

Left  lower     5" 

1.0 

In  gonococcal  immunization  the  same  form  of  record  is  adopted 
except  that  the  third  column  shows  the  number  of  organisms  in  each 
cubic  centimeter  and  changes  with  the  selection  of  stronger  bacterins. 

1  This  method  of  dividing  the  glutei  iato  quadrants  is  fully  described  by  the  author, 
"Intramuscular  Injections  in  the  Treatment  of  Syphilis,"  New  York  State  Med.  Jour  , 
March.  1909. 


(11  AP'l'Kli    X. 
GONOCOCCAL  INKKCTIOX   L\  TIIK  FKMAI.K. 

ANATOMY  OF  THE  FEMALE  UROGENITAL  SYSTEM. 

Importance.— Detailed  anatomy  cannot  be  <;ivon  for  lack  of  space. 
The  reader  w'\\\  consult  works  on  gross  anatomy  and  on  normal  and 
pathological  minute  anatomy.     In  the  female  sexual  and  urinary  sys- 


FALLOPIAN   TUBE 
PAROOPHOR 


RJFICE 
AN   TUBE 


INFUNDIBULUM    OF 
FALLOPIAN   TUBE 


PAVILION    OF 
FALLOPIAN  TUBE 


ORGAN    OF 
ROSENMULLER 


NUS 
BIUM 
AJUS 


VESTIBULE   OF  VAGINA 

Fig.  121. — Diagram  of  the  female  reproclucti\e  organs  and  of  their  rehitious  to  the 
bladder  and  urethra  in  lateral  \-ic\v.  The  continuity  of  .surface  between  the  lal)ia  majora 
and  minora  externally  and  the  vagina  cavity  of  the  uterus  and  tubes  in  the  sexual  system 
and  the  continuity  of  surface  between  the  external  organs  and  the  urethra,  bladder, 
ureters  and  kidneys  of  the  urinary  system  are  clearly  shown.     (Toldt.') 

tems  there  exists  continuity  in  all  organs  of  their  mucous  membrane 
linings  as  shown  in  Fig.  121.  This  is  the  principle  which  must  be 
remend)ered  in  the  surgery  of  an  infection  like  the  gonococcal. 

Gross  Anatomy. — In  the  urinary  system  the  plan  is  the  same  as 
that  in  the  male.    In  the  sexual  system  the  secretory  glands  are  the 


•  Ad  Atlas  of  Human  Anatomy,  1904,  section  iv,  p.  500. 


UROGENITAL  INFECTIONS  IN  GENERAL 


525 


ovaries,  from  which  continuous  canals  be^in  with  each  tube  and  end 
primarily  with  the  os  externum  uteri  and  with  the  vuh'a  secondarily. 
These  relations  are  illustrated  in  Fig.  121. 

Minute  Anatomy. — The  universal  mucous  lining  is  closely  similar 
from  system  to  system  and  organ  to  organ.  Function  determines  the 
epithelial  and  glandular  details.  As  in  all  other  mucosa*,  those  of  these 
systems  react  unfavorably  to  infection  through  jjoor  resistance  and  slow 
recovery.  Chronic  inflammation  is  \'ery  common,  with  tempjorary  or 
permanent  damage  in  epithelial  modification  in  mild  cases  and  mem- 
branous destruction  in  severe  cases.  These  general  facts  must  never 
be  forgotten  in  diagnosis  and  treatment. 


Fig.  122. — Transverse  section  of  the  mucous  gland  from  the  body  of  the  human 
uterus.  1,1,  gland  with  central  canal  and  ciliated  cylindrical  epithelium;  2,  basal  mem- 
brane of  the  wall  outside  in  wliich  is  seen  the  mucous  chorion.     (Nagel.^) 

UROGENITAL  INFECTIONS  IN  GENERAL. 

Varieties. — ^A^arieties  are  determined  by  the  organ  infected  and  by 
the  form  of  infection.  There  are  therefore  distinguished  according  to 
the  organ  attacked:  (1)  In  the  minary  system,  urethritis,  urethro- 
cystitis, cystitis,  m-eteritis,  pyelitis,  as  pyelonephi'itis,  as  individual  or 
associated  lesions;  and  (2)  in  the  sexual  system  vulvitis,  vestibular 
adenitis,  vaginitis,  cervicitis,  endometritis,  salpingitis,  oophoritis,  and 
peritonitis  sometimes  as  individual  but  more  commonly  as  associated 
lesions.  According  to  the  form  of  infection  for  our  purposes  there  are 
two  classes,  the  nongonococcal  and  the  gonococcal,  of  which  as  sexually 
acquired  diseases  the  latter  is  by  far  the  most  common  but  among 
partinient  lesions  the  former  is  similarly  frequent. 

Pathology  is  in  all  its  features  analogous  to  that  in  the  male  in  both 
the  gonococcal  and  the  nongonococcal  forms.  The  former  is  om'  ty^e. 
The  essence  of  the  process  is  an  invasion  of  the  organism  with  des- 
quamation and  moderate  exudation  followed  by  penetration  and  free 
pus  formation  and  more  or  less  destruction.  Later  there  is  cell  sub- 
stitution and  a  change  from  specialized  epitheliiun  to  squamous  and 


1  Die  weiblichen  Geschlechtsovgane,  1S96,  p.  89. 


526       GOXOCOCCAL  INFECTION  IN  THE  FEMALE 

from  squamous  epithelium  to  true  eieatrix.  The  tissues  are  the  mucosa 
in  the  primary  involvement  followed  by  the  submucosa,  the  jxlands  and 
the  substance  of  the  organ  itself.  Such  lesions  are  seen  in  the  urethra, 
vuha.  \agina.  cervical  iind  cori)oreal  endometrium,  and  oviducts  in 
the  ]irimary  ]>rocess  but  in  the  secondary  extensions  into  the  innnary 
system,  the  bladder,  ureters  and  kidneys  and  in  the  sexual  system  the 
uterus,  ovaries  and  peritoneal  cavity  are  invaded.  The  system  at 
large  may  sutTer  through  such  extension  in  either  of  these  regions  of 
the  body.  The  types  of  lesion  arc  analogous  of  those  in  the  male  as 
well  as  the  tendency  to  extension  and  penetration.  The  temporary 
lesions  are  seen  only  in  mild  cases  and  in  less  in\'olved  regions  of  severe 
cases  and  have  the  faculty  of  advance  from  focal  points  to  general  or 
disseminate  forms.  The  permanent  lesions  know  no  precise  Hmit  as 
all  and  any  varieties  and  correlations  of  lesions  within  the  lining  and 
the  substance  of  the  organs  of  both  the  urinary  and  sexual  systems  are 
seen.  The  annexa  of  the  uterus  furnish  the  best  illustration  as  is  noted 
by  Norris:^  "In  the  latter  location  the  prolongation  of  symptoms  may 
be  traced  to  three  definite  causes:  reinfection,  either  autoinfection 
from  the  cervix  and  endometrimu,  or  from  without,  may  occur;  or 
secondary  infection  may  result  and  the  lesions  be  actively'  continued  by 
organisms  other  than  the  gonococcus;  and,  lastly,  the  scar  tissue  or 
adhesions  resulting  from  the  active  infection  may  ]:)ersist  and  produce 
s\in])toms."  AVhereas  this  ciuotation  conjoins  pathology'  with  symj)- 
tomatology  it  is  a  re\'elation  of  the  pathologic  element.  In  the  glands 
the  ducts  may  close  and  true  retention  abscesses  with  the  parenchjana 
and  capsule  of  the  gland  destroyed,  leaving  a  true  pyogenic  membrane 
and  forming  a  topical  phlegmon.  Or  the  ducts  may  shut  and  the 
destruction  be  much  less  and  cysts  may  form.  Or  the  duct  and  gland 
may  be  profoundly  diseased  without  occlusion  and  continue  to  dis- 
charge as  a  sinus  persistently  or  intermittently.  Any  of  the  glands  may 
be  so  affected,  for  example,  the  mucous  crypts  of  the  ^'ul^'a  and  vagina, 
the  more  complex  glands  of  the  cervix  and  endometrium,  Skene's  glands 
in  the  m-ethra  and  the  vestibular  glands.  All  these  details  duplicate 
the  process  in  the  male  in  homologous  regions.  The  associated  lesions 
are,  as  in  the  male,  depreciated  tissue  and  visceral  resistance  which  are 
locally  prmiary  processes  followed  by  lowered  general  resistance  often 
as  the  secondary  lesion.  Thus  pyogenic  infection  from  within  such  as 
the  Bacillus  coli  and  Bacillus  tuberculosis  or  from  Avithout  such  as  the 
Bacillus  tuberculosis,  Streptococcus  and  Staphylococcus  pyogenes  are 
directly  invited  and  it  is  at  least  likely  that  neoplastic  change  is  more 
readily  developed  in  such  damaged  than  in  normal  organs.  Sterility 
and  ectopic  gestation  are  such  common  sequels  as  to  be  almost 
invariable. 

The  complicating  lesions  are  properly  only  those  which  involve  organs 
in  less  direct  continuity  with  the  vulvovaginal  outlet.  They,  therefore, 
include  the  urinary  system  above   the  sphincter  vesica?  and  other 

'  Gonorrhea  in  Women,  1913,  p.  88. 


UROGENITAL  INFECTIONS  IN  GENERAL  527 

mucous  membranes,  such  as  those  of  the  mouth  and  rectum,  nose  and 
eye  and  finally  any  organ  of  the  f^eneral  system,  '^ilius  the  female 
experiences  the  same  compli(;ations  as  the  male.  J^>xtensioris  of  the 
infection  from  one  part  of  the  sexual  mucosa  to  another  should  be 
regarded  as  added  invasions  or  as  progress  from  part  to  part  of  the 
same  field  and  not  as  complications. 

Etiology. — Etiology  recognizes  the  same  factors  as  in  the  male  in 
the  classification  of  local  and  systemic,  predisposing  and  exciting  factors 
and  finally  bacterial  causes.  Sufficient  discussion  of  all  but  the  last  will 
be  found  in  the  corresponding  paragraphs  on  the  male.  The  bacterial 
elements  are  nongonococcal  and  gonococcal  and  in  the  nongonococcal 
lesions  are  noted  the  same  dyscrasise  for  the  eruptive  and  diathetic  forms, 
the  same  trauma  by  heat,  cold,  chemicals,  violent  intercourse,  unnatural 
practices  and  rape.  The  Micrococcus  catarrhalis  causes  the  catarrhal 
lesions  often  grafted  on  a  cured  gonococcal  infection  or  the  damaged 
organs  of  miscarriage  and  childbirth.  The  specific  organisms  of  syphilis 
and  chancroid  are  discussed  in  these  forms  of  urethritis  in  the  male  on 
pages  29  and  30.  Almost  equally  important  as  gonococcal  suppura- 
tion is  pyogenic  infection  most  commonly  arising  from  the  Strepto- 
coccus and  the  Staphylococcus  pyogenes  and  the  Bacillus  coli  in  pure 
culture  or  association  with  each  other  or  the  gonococcus. 

The  gonococcal  lesions  are  the  most  usual  and  in  sexually  acquired 
afflictions  practically  the  sole  cause.  The  gonococcus  appears  in  pure 
culture  -or  associated  with  the  organisms  just  stated  or  with  those 
enumerated  in  paragraphs  dealing  on  this  subject  on  page  22.  Pri- 
mary infections  are  the  rule  but  often  they  are  secondary  to  other 
urinogenital  disease,  such  as  catarrhs  after  miscarriage  and  childbirth. 
The  value  of  careful  laboratory  investigation  as  to  the  number,  mor- 
phology and  activity  of  the  gonococcus  is  spoken  of  under  this  title  in 
etiology  in  the  male  on  pages  24  to  27. 

Bacteriology.^ — ^The  bacteriology  of  the  gonococcus  is  the  same  as 
detailed  for  the  male  and  rests  somewhat  on  the  number,  morphology 
and  virulence  of  the  organism  on  the  following  general  principles:  In 
the  incubation  (late)  and  in  the  invasion  (early)  the  exudate  is  mucus 
and  serum  mixed  with  epithelia,  red  blood  cells,  scattered  pus  cells 
and  detritus.  The  gonococci  are  few  and  scattered  or  occasionally 
more  numerous,  usually  extracellular,  floating  in  the  mucus  and  serum 
and  occasionally  supracellular  and  stiU  more  rarely  intracellular.  The 
distinction  between  the  last  two  is  by  focussing  and  by  detecting  overlap 
or  overhang  of  the  organisms  beyond  the  margin  of  the  pus  or  epithelial 
cells.  In  the  invasion  (late)  or  in  the  establishment  (early)  the  discharge 
is  mucopurulent  and  the  pus  cells  are  an  obvious  and  increasing  factor 
and  the  gonococci  are  much  more  numerous  with  intracellular  relation 
conspicuous,  supracellular  position  common,  and  extracellular  freedom 
decreasing  or  rare.  In  the  establishment  (full)  pus  cells  predominate 
over  all  other  elements,  even  masking  red  blood  cells,  epithelia  and 
detritus.  The  gonococci  are  more  numerous,  as  a  rule,  but  in  com- 
parison with  the  redundance  of  pus  cells  they  may  appear  less  numerous 


528  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

than  in  other  stages.  In  the  ternunation,  aecording  to  Cniiteras,'  the 
pus  cells  progressi\ely  decrease  and  degenerate,  showing  fat  globules. 
The  gonococci  are  few  and  hard  to  find  and  desquamation  of  e])ithelia 
continues.  The  activity  of  ])us  formation  and  the  i)ersistence  of  gono- 
C(H"ci  are  elosely  related  so  that  the  former  is  an  index  of  the  latter  and 
of  infectiousness. 

In  the  chronic  or  shred  stage  a  \  ariety  of  conditions  appear.  Pus, 
epithelium  and  detritus  with  extracellular  and  intracellular  gonococci 
mark  active  shreds.  ]\Iucus,  ei)ithelia  and  detritus  with  few  or  no 
gonococci  indicate  more  nearly  cured  cases.  It  is  in  this  ])eriod  that 
inversion  forms  of  the  gonococcus  appear  and  other  organisms  such  as 
the  Micrococcus  catarrhalis  are  in  e^•idence  prolonging  the  discharge. 
It  is,  therefore,  in  this  stage  perha])s  more  than  in  any  other  that 
culture  of  the  specimen  nuist  be  made  by  a  skilled  laboratory  cxjjcrt 
for  final  conclusions. 

The  clinical  symptoms  and  coiu'sc  progress  pari  i)assii  with  the 
number  and  virulence  of  the  infecting  organisms  in  gonococcal  as  in 
other  disease.  Unfortiuiately,  bacteriology  on  account  of  technical 
dilHculties  of  prompt  distinction  between  the  various  strains  of  the 
gonococcus  cannot  foretell  mild  from  severe  cases.  Clinical  evidence 
outweighs  all  other  evidence,  but  the  microscope  on  the  foregoing 
})rinciples  is  of  great  valtie  when  they  are  applied  to  a  large  niunber  of 
smeai-s  taken  at  the  same  time,  because  the  condition  of  one  smear  may 
be  peculiar  to  that  smear  and  not  an  index  of  the  number  of  germs  and 
pus  cells  and  other  exudate  in  the  case  per  se. 

Pathology. — Pathology  in  its  general  features  duplicates  that  found 
in  the  male;  but  the  pathological  varieties  differ  in  children  and  adults. 
In  the  child  there  are  severe  mucosal  lesions  with  somewhat  less  organic 
and  peritoneal  change  because  the  organs  are  undc\'eloped;  but  in 
adults  all  the  organs  may  be  profoundly  affected  and  the  peritoneum 
included  in  the  process.  Infantile  uterus  is  assumed  to  be,  in  many 
cases,  the  outcome  of  infantile  gonococcal  disease  through  atrophv'  of 
the  endometrium  and  metrium. 

The  primary  cases  are  those  of  initial  infection  without  any  ante- 
cedent or  causal  condition  and  the  secondary  cases  are  the  relapses  of 
previous  gonococcal  disease  or  new  infections  of  other  lesions,  such  as 
the  damage  of  chiklbirth.  The  essence  and  stages  are  those  seen  in 
the  male  and  include:  (1)  inoculation,  which  except  for  the  presence 
of  the  gonococcus  and  its  colonization  is  M'ithout  lesions ;  (2)  incubation, 
which  shows  the  growth  of  the  organisms,  the  earliest  degree  of  des- 
quamation and  a  mucous  serous  or  mucoserous  exudate;  ('■])  establish- 
ment, which  is  des(piamation  in  full  development,  purulent  or  blood 
discharge,  and  inffltration  of  small  round  cells  and  white  blood  cells, 
and  (4)  termination,  which  is  slow  subsidence  of  the  other  processes, 
effort  at  repair  but  often  with  replacement  of  specialized  epithelium 
with  squamous  cells  or  substitution  of  squamous  epithelium  with  true 

1  Urologj-,  1912,  ii,  358, 


URETHRITIS  529 

scar  tissue.  Chronic  local  catarrhal  inflammation  often  persists  as  a 
sequel. 

The  tissues  and  organs  involved  are  regularly  the  mucous  membrane 
of  any  part  of  the  urinogenital  tract  from  which  the  disease  by  pene- 
tration may  involve  the  substance  of  the  organs  themselves  as  is  seen 
in  the  extension  of  endometritis  to  metritis  and  of  cystitis  to  pan- 
cystitis  and  of  pyelitis  to  pyelonephritis  or  renal  abscess.  The  temporary 
lesions  are  such  as  affect  the  surface  of  the  mucosa  alone  as  in  mild 
cases  or  in  less  involved  zones  of  severe  cases,  while  the  permanent 
lesions  represent  penetration  of  the  disease  and  destruction  more  or  less 
profound  and  widely  distributed.  The  associated  lesions  are  the  same 
process  located  in  other  organs  of  the  same  system,  as  the  vagina  and 
uterus  in  the  sexual  organs  or  as  the  urethra  and  bladder  in  the  urinary 
viscera.  They  may  also  be  the  same  lesion  in  adjoining  organs  of  the 
two  systems  as  the  invariable  occurrence  of  vulvovaginitis  and  ureth- 
ritis. The  complicating  lesions  are  the  disease  in  extragenital  systems, 
such  as  the  mucosa  of  the  eye,  rectum,  respiratory  system  and,  in  the 
body  at  large,  as  in  arthritis.  Details  of  the  pathology  are  briefly 
mentioned  under  each  organ. 

Symptomatology. — Symptoms  in  general  characters  are  like  those  in 
the  male.  In  children  they  are  chiefly  objective  through  the  absence 
of  descriptive  power  other  than  that  of  pain.  In  the  primary  cases  one 
is  dealing  wdth  initial  and  immediate  infection  and  its  syndrome;  but 
in  the  secondary  cases  almost  any  antecedent  condition  may  mask  the 
onset,  establishment  and  course  of  the  disease.  As  in  any  other  disease, 
the  forms  are  hyperacute,  which  is  rare,  acute,  which  is  the  average 
case,  subacute,  which  is  the  declining  period  and  chronic,  which  marks 
a  protracted  or  a  incomplete  termination  and  the  periods  are  those  of 
invasion,  establishment  and  termination.  In  the  average  case  the  sys- 
tems involved  are  the  sexual  system  in  part  or  whole  and  the  urinary 
system  as  to  the  urethra  in  all  cases  and  the  upper  tract  in  complicated 
cases,  which  may  otherwise  add  any  remote  mucous  tract  or  organ  of 
the  body. 

The  clinical  featiu-es  of  the  disease  will  be  considered  as  they  appear 
in  each  organ  of  the  sexual  and  the  urinary  systems. 

I.  Urinary  System. 

URETHRITIS. 

Varieties. — ^Varieties,  as  in  the  male,  are  nongonococcal  and  gono- 
coccal, of  which  the  former  is  far  less  common  and  important  than 
the  latter,  which  is  almost  the  uniform  rule  in  disease  sexually 
acquired. 

Nongonococcal  Urethritis. — Nongonococcal  urethritis  is  much  less 

obvious  in  the  female  than  in  the  male  on  account  of  the  short  urethra 

and  wide  open  \'ulva.    The  varieties  are  the  eruptive  and  diathetic, 

which  are  very  uncommon,  while  the  catarrhal,  traumatic,  s^^philitic, 

34 


530 


GOXOCOCCAL  IXFKCTinX  IX  THE  FEMALE 


GDcijy 


Fig.  123. — Female  urethra  from  above.  The  anterior  or  upper  wall  of  the  urethra 
and  bladder  have  been  removed  and  the  mucosa  extended.  1,  bladder;  1'  neck  of  bladder; 
2,  urethra,  with  longitudinal  folds  and  glandular  outlets;  3,  crest  of  the  urethra;  Jf, 
urethral  muscularis;  5,  external  si)hincter;  6,  urinary  meatus;  7,  vaginal  tubercle;  5, 
vagina;  9,  labia  minora;  10,  clitoris;  11,  prepuce  of  clitoris.     (Testut.') 


Fig.  124. — Acute  venereal  ulcer  or  chancroid  of  the  \'ulva.  Smear  from  the  pus. 
Methylene-bhie  stain.  (800  diameters.)  In  the  field  arc  shown  numerous  characteristic 
straight  or  .slightly  curved,  long,  rather  thick  bacilli  with  almost  sfiuarc  ends.  As  a  rule, 
they  occur  singly  but  occasionally  in  short  chains  and  mostly  extracellular  although 
exceptionally  intracellular.     (Lipschiitz.^) 


>  Trait6  d'Anatomic  Humaiiie,  Gth  cd.,  1911-12,  vol.  4. 
2Loc.  cit. 


PLATE    X 


Gonococcal  Chronic  Urethritis  in  tl:ie  Female.     (Lipschutz.^) 

Smear  of  secretion  secured  by  expression  of  glands.  Grani's  stain  (lOOO 
diameters).  In  the  field  are  several  polynuelear  leukocytes  filled  with  typical 
gonococei  in  contrast  stain.  A  fe\v  gonoeoeci  are  extracellular.  Short 
diplobaeilli,  stained  blue-black,  are  contrasted  -with  the  gonoeoeci  and  are 
seen  extracellular  and  intracellular.  During  the  acme  of  the  gonoeoeeal 
inflamniation,  through  the  multiplication  and  activities  of  the  gonococei, 
the  presence  of  the  normal  flora  of  the  mucosa  is  masked.  When, 
however,  the  chronic  stages  supervene  the  normal  organisms  reappear 
without  great  influence  on  the   gonococei. 


iBacteriologischer  Grundriss  und  Atlas  der  Geschlecbtskrankheiteu.   1913. 


URETIfRfTIS  531 

chancroidal  and  suppurative  differ  in  no  material  degree  from  those  of 
the  male  except  in  the  factor  that  the  urethra  in  woman  is  the  lionio- 
logue  of  the  posterior  portion  in  the  male  and  that,  therefore,  irritation 
of  the  bladder  is  often  an  early  symptom.  The  causes  also  do  not  differ 
in  the  two  sexes.  In  clinical  features  these  forms  are  more  or  less  like 
very  mild  degrees  of  gonococcal  invasion,  which  is  taken  as  the  ty[)e. 
Fuller  details  are  given  in  the  sections  of  this  work  dealing  with  the 
male.  Suppurative  nongonococcal  urethritis  may  equal  the  gonococcal 
in  severity,  course,  termination  and  complications  and  is  then  dis- 
tinguished from  it  only  bacteriologically. 

Gonococcal  Urethritis. — Varieties. — The  varieties  are  acute,  subacute 
and  chronic  and  the  etiology  is  regularly  the  gonococcus  in  pure  or 
mixed  culture.  The  gross  pathology  during  the  acute  period  is  that  of 
a  severe  suppurative  inflammation  of  the  mucosa  with  unmistakable 
desquamation,  penetration  and  infiltration.  It  shows  as  gross  lesions 
a  meatus  with  redness,  edema,  bogginess,  tenderness  and  thickening, 
followed  by  glandular  disease  as  in  Skene's  glands  and  in  abundant 
generalized  highly  infectious  purulent  exudate.  During  the  subacute 
or  declining  state  infiltration  of  the  mucosa  and  less  discharge  are  the 
features.  These  may  all  be  temporary  lesions  and  recovery  from  them 
complete;  but  in  the  chronic  stage  almost  any  permanent  lesion  may 
appear,  such  as  persistent,  suppurative  or  catarrhal  inflammation,  obsti- 
nate abscess  or  sinus  and  even  cicatrix  infiltration,  dryness  and  glandu- 
lar destruction,  exactly  as  in  the  male.  The  microscopic  lesions  are 
congestion,  hyperemia,  desquamation  and  purulence  as  the  temporary 
signs  and  cellular  substitution,  scar  tissue  formation,  abscess  and  sinus 
as  the  permanent  result,  as  further  detailed  in  the  section  on  the  male 
on  page  32. 

Symptoms. — The  urethra  is,  if  not  primarily,  always  secondarily, 
invaded  by  the  gonococcus,  which  marks  the  significance  of  urethritis 
as  great.  The  relation  of  the  meatus  to  the  introitus  of  the  vagina 
makes  infection  through  intercourse  almost  certain  to  reach  the  urethra 
combined  with  the  mild  trauma  of  coitus.  The  meatus  urinarius  consists 
of  a  folded  dimple  in  the  nonparous  woman  closed  by  two  prominent 
labia  but  in  the  parous  female  this  outlet  gapes  exactly  as  the  vulva 
does.  The  disease  may  be  ascending  from  its  urethro vulvar  focus  or 
descending  from  the  cervix  and  vagina.  The  s^Tnptoms  are  therefore 
often  masked  by  accompanying  acute  or  chronic  vulvovaginitis  and 
vary  with  acute  and  chronic  forms  and  may  be  classified  as  local  and 
systemic,  subjective  and  objective. 

The  subjective  local  acute  s^Tiiptoms  are  sensory  and  functional. 
The  invasion  is  marked  by  discomfort  and  tickling  followed  by  a  watery, 
then  a  mucous  moisture  and  by  slight  frequency  of  urination.  The 
establishment  changes  the  sensations  to  positi^'e  pain  and  burning  of 
urination  and  still  greater  pain  when  the  glandules  are  involved  and 
modifies  the  discharge  to  active  purulence  and  sometimes  slight  hemor- 
rhage. Rupture  of  glandular  abscesses  adds  more  pus.  In  more  severe 
cases  pollakiuria  and  tenesmus  appear  exactly  as  in  the  male. 


532  GONOCOCCAL  INFECTIOX  IN  THE  FEMALE 

The  siibjectiA'e  and  objoctivc  systemic  acute  s>nnptoms  are  either 
absent  or  there  are  chill  and  fever  and  other  signs  of  acute  pus  process. 

The  objective  local  acute  symjitonis  are  circulatory  change,  discharge, 
prominence,  eversion,  infiltration  and  glandular  enlargement  of  the 
mucosa.  In  the  invasion  the  h.^peremia  is  evident  and  progresses  and 
the  discharge"  is  scanty  niiicus  or  serum.  Thickening  of  the  canal  is 
absent  and  glandular  infection  doubtful.  In  the  establishment  when 
the  pain  and  frequency  are  great,  redness,  prominence,  eversion  and 
infiltration  of  the  mucosa  appear.  The  discharge  is  abimdant,  purulent 
and  even  hemorrhagic  and  easily  expressed  by  stripjjing  with  one,  or 
better,  two  fingers.  Skene's  glands  show  as  reddened  ])oints,  discharging 
droplets  of  pus,  and  other  glands  of  the  urethra  are  like  hardened  spots 
whose  contents  evacuate  on  pressure.  The  whole  canal  is  infiltrated 
and  edematous  and  the  glands  being  most  numerous  along  the  floor 
lead  to  suburethral  abscesses  as  described  by  Hey,^  in  1805.  The 
paraurethral  glands,  when  present,  may  also  become  involved  and 
discharge  cither  into  the  urethra,  upon  the  vestibule  or  into  the  vagina. 
Gonococci  are  abundant  in  the  discharge  in  all  these  stages  on  smear 
and  culture  test  and  often  urinalysis,  but  in  the  female  the  multiple 
glass  tests  of  the  lu'ine  cannot  be  applied.  In  the  termination,  the  mild 
cases  subside  and  go  on  to  cure  without  sequels  or  complications,  but  the 
a\'erage  and  the  severe  cases  show  a  slow,  irregular  subsidence  due  to 
glandular  disease  and  discharge  w^hich  may  be  accompanied  more  or 
less  with  urinary  frequency,  ardor  and  tenesmus  as  the  glands  relapse 
in  their  disease.  Still  other  cases  become  truly  chronic  almost  exactly 
as  in  the  male. 

Clironic  urethritis  shows  few  subjective  symptoms  but  occasionally 
there  is  urinary  disturbance  or  urethral  discomfort  through  the  lighting 
up  of  glandular  infection.  Objective  signs  are  much  more  important, 
because  pressure  on  the  glands  reveals  shotlike  masses  which  exude  a 
drop  of  pus  usually  containing  the  gonococcus,  infiltration  and  stricture 
of  the  mucosa,  and  sinuses  and  fistulse  of  minute  abscesses,  which  have 
discharged  into  the  vagina  or  vestibule  instead  of  into  the  urethra. 
The  tendency  of  the  urethral  mucosa  to  have  persistent  catarrhal  or 
suppurati\'e  discharge  even  after  the  gonococcus  has  disappeared  is  as 
common  in  woman  as  in  man. 

Diagnosis.— The  recognition  of  gonococcal  acute  m-ethritis  in  the 
female  is  usually  easy  and  rests  on  the  four  factors  emphasized  through- 
out this  work.  In  the  history  are  the  elements  of  illicit  intercourse  or 
of  "weakness"  soon  after  marriage  introducing  the  typical  syndrome 
of  infection.  Or  later  in  wedlock  the  husband  may  be  known  to  have 
been  diseased.  ]Most  significant  is  the  record  of  vulvovaginitis,  as 
m-ethritis  rarely  occurs  alone.  The  symptoms  are  those  of  moderate 
or  severe  urinary  disturbance,  pain,  frecpiency,  tenesmus,  occasionally 
bleeding,  together  with  those  of  the  antecedent  or  concomitant  vulvo- 
vaginitis.   The  physical  examination  verifies  the  presence  of  pus  and 

1  Practical  Observations  in  Surgery,  Philadelphia,  IbOo,  p.  304. 


URETHRITIS  533 

other  signs  of  inflammation,  and  the  laboratory  findings  are  the  most 
important.  It  is  usual  for  aeute  urethritis  to  d(;velop  abundant  pus 
in  which  the  gonococcus  is  rare  in  the  early  invasion  but  very  common 
and  numerous  in  the  establishment  and  again  decreases  in  the  termi- 
nation unless  glandules  have  become  invaded.  Evacuation  of  these 
develops  a  drop  of  pus  invariably  containing  the  gonococcus  or  its 
allies.  On  the  other  hand  chronic  urethritis  requires  careful  stripping 
of  the  urethra  best  with  two  fingers  in  the  vagina  and  the  evacuation 
of  Skene's  glands  with  the  hairpin  method.  Fistulas  and  sinuses  are 
likewise  treated.  The  urethroscope  studies  and  localizes  such  lesions 
in  the  canal  and  Garceau^  meatoscope  is  of  aid. 

In  all  cases  a  single  negative  determination  cannot  be  trusted  but 
must  be  consistently  supported  by  a  series  of  negative  reports.  Smear 
and  culture  are  mutually  corroborative  and  the  gonococcal  comple- 
ment fixation  test  is  reserved  for  the  complicated  examples.  In  the 
treatment  the  value  of  antigonococcal  measures  aids  in  the  proof. 
During  the  treatment  specimens  of  final  character  are  often  obtained. 

Treatment.— Urethritis  in  the  female  is  very  rarely  indeed  the  sole 
infection.  The  eyes  come  first  in  prophylaxis  in  the  ordinary  cleanli- 
ness of  the  fingers  and  the  proper  burning  of  dressings.  Extension  from 
the  urethra  to  the  bladder  is  prevented  by  urinary  antiseptics,  such  as 
boric  acid,  salol,  hexamethylenamin  and  benzoate  of  soda.  The  vulva, 
vagina  and  cervix,  if  normal,  are  carefully  protected  during  the  local 
treatment  of  the  urethra.  Coitus  is,  of  course,  forbidden.  Abortive 
treatment,  as  in  the  male,  rests  on  immediate  bacteriologic  diagnosis 
and  the  applications  and  instillations  of  the  same  germicides.  The 
simple  character  of  the  symptoms  attracts  so  little  attention  that 
these  measures  can  rarely  be  applied. 

Enumeration  of  details  of  management  is  contained  in  Chapter  IX 
on  General  Principles  of  Treatment  on  page  483. 

Curative  Treatment. — ^The  acute  period  rapidly  passes  into  the  chronic 
and,  as  in  the  male,  attacks  of  attenuated  strains  of  the  gonococcus 
may  recover  with  little  attention. 

The  physical  measures  begin  with  hydrotherapy  and  chiefly  with  very 
hot  sitting  baths,  as  detailed  in  the  male,  to  decongest,  soothe,  and 
decrease  the  pain,  frequency  and  irritation.  Douches  applied  with  the 
patient  on  a  bed-pan  and  a  pitcherful  of  hot  solvents  of  pus  are  useful. 
Normal  salt  solution  or  sterile  water  is  the  best  and  these  are  followed 
by  hot  weak  antiseptic  solutions  and  a  dressing  to  protect  the  vulva. 
The  dressing  for  the  discharge,  as  in  the  male,  should  not  bottle  up  the 
exudate,  which  should  have  free  outlet.  Infection  of  the  annexa  of  the 
urethra  is  avoided  through  frequent  changing.  As  in  the  male,  the 
cavity  of  the  urethra  should  be  left  alone  mitil  the  declining  period  is 
well  established.  This  obviates  unexpected  increase  in  the  severity  of 
symptoms  and  the  extension  and  penetration  of  the  gonococci.  As  in 
the  male,  foreign  bodies  in  the  lu-ethra  are  not  advised,  such  as  gauze 

1  Surg.,  Gynec.  and  Obst.,  January,  1912,  p.  80. 


534  GOXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

or  cotton  and  medicated  hou^ies.  Their  irritation  is  greater  than  their 
medication  and  tlie  reaction  exceeds  tiie  l)enefit. 

The  medicinal  treatment  of  the  acute  period  follows  the  rule  in  the 
opposite  sex.  The  local  measures  leave  the  urethral  cavit\'  itself  alone 
until  the  severe  sym])toms  subside,  as  in  the  male.  Irrigation  in  the 
method  em])loyed  in  men  is  not  easily  j)ossihle  on  account  of  the  short 
canal  and  the  proximity  of  the  bladder,  although  the  \'alentine-Janet 
method  otters  special  nozzles  for  this  purpose.  It  is  better  to  inject 
small  quantities  of  the  antiseptics  with  a  small  cone-point  urethral 
springe  or  a  medicine  dro])per,  followed  later  by  instillations.  The 
solutions,  frecjuency  and  other  data  are  the  same  as  in  men.  Above 
all,  the  patient  always  urinates  first  to  wash  out  as  much  pus  as  possible. 
The  best  fluid  of  all  is  nitrate  of  silver  properly  graduated  so  as  not  to 
cause  irritation  or  reaction.  Argyrol  3  to  20  ])er  cent,  or  ])rotargol  I  to 
5  i)er  cent,  and  jiotassium  i)ermanganate  1  to  SOOO  to  1  to  'MM)  are 
excellent.  The  weaker  strengths,  greater  frequency  and  injection 
method  a^•ail  for  the  earlier  periods,  while  greater  concentration, 
longer  intervals  and  instillations  are  for  the  subacute  and  chronic 
periods.  The  medicine  dropper,  small  male  urethral  hand  syringe  and 
the  soft-rubber  catheter  with  Janet-Frank  syringe  or  with  the  Hayden 
instillating  syringe  are  all  available.  The  retention  of  urine  after 
each  treatment  for  several  hours  permits  penetration  of  the  ap})li- 
cation. 

The  systemic  medication  comprises  the  urinary  diluents,  antiseptics 
and  balsams,  resins  and  oleoresins.  The  selection,  combination  and 
prescription  correspond  with  those  in  the  male. 

In  the  chronic  stage  the  progress  is  slow,  the  course  long  and  the 
condition  due  to  early  faulty  or  o\eractive  treatment.  Prophylaxis 
considers  tlie  patient  herself  and  her  neighbors.  Her  suffering  is  so 
slight  that,  like  men,  women  neglect  the  condition  and  full  cooperation 
is  difficult  to  obtain.  Thus  frequent  infections  in  wedlock  and  in 
prostitution  occur.  The  local  measures  are  as  follows:  The  amount 
of  pus  ma>'  be  ^•ery  little  and  arise  in  a  generalized,  localized  or  dis- 
seminate folliculitis.  Infection  of  wSkene's  glands  is  common  and 
usually  bilateral.  The  best  diagnostic  step  is  to  support  the  urethra 
with  two  fingers  in  the  vagina,  close  together,  with  the  urethra  in  the 
inter^•al  between  them  and  steadied  from  rolling  out  of  reach.  A 
sterilized  hairpin  is  used  to  express  the  contents  of  first  one  gland  and 
then  the  other.  This  disease  is  cured  by  instillation,  incision  or 
excision.  With  a  hypodermic  syringe  and  blunted  needle,  nitrate  of 
silver  is  instilled  in  strength  of  2  to  10  per  cent,  or  more,  protargol  3  to 
5  per  cent.,  argyrol  10  to  20  per  cent.,  chromic  acid  2  to  10  per  cent. 
The  systemic  administration  continues  to  modify  those  of  the  acute 
stages  seen  in  the  male.  They  preserve  the  urine  in  non-irritating 
condition,  stimulate  the  mucosa  and  maintain  proper  diet  and  habit. 

The  surgical  measures  are  chiefly  operative,  as  the  non-operative 
measures  are  included  under  local  treatment.  Skene's  glands  and 
stricture  are  the  chief  fields.     Skene's  glands  may  be  excised  exactly 


GONOCOCCAL  WLVITIH  535 

like  the  vulvovaginal  glands,  hnt  incision  is  better.  Skene's'  teehnic 
is  as  follows:  A  probe  is  pressed  to  the  bottom  of  the  gland  and  a  free 
incision  is  made  along  the  floor  of  the  urethra  from  the  vestibule.  The 
cavity  and  substance  of  the  gland  are  then  destroyed  with  the  actual 
cautery.  A  similar  procedure  may  be  followed  from  within  tin;  urethra 
by  retracting  the  meatus  with  the  wire,  the  Skene-Folsom  meatoseope, 
with  hairpins  bent  to  a  right  angle  and  grasped  in  artery  clampis  after 
the  method  of  Hunner^  or  with  an  Outerbridge  intrauterine  pessary  as 
preferred  by  Taussig.'' 

Aftertreatment. — In  both  sexes  afflicted  with  gonococcal  urethritis 
the  immediate  aftertreatment  is  continuation  of  good  habits  in  diet, 
drink  and  sexual  relations.  The  patient  should  be  kept  under  close 
observation  against  reinfection  and  relapse.  The  remote  aftercare  is 
thorough  and  repeated  bacteriologic  examination  in  the  quiescent 
and  stimulated  conditions  until  a  negative  result  is  consistently  main- 
tained.   Only  then  may  family  life  be  resumed. 

Cure. — It  is  essential  for  the  patient  that  the  cure  be  absolute,  both 
pathologically  and  symptomatically.  It  is  necessary  for  husband  and 
community  that  the  cure  be  bacteriologically  perfect,  in  other  words 
the  social  side  of  the  matter  is  as  important  in  the  female  as  in  the  male. 
The  gonococcal  complement  fixation  test  is  rarely  positive  in  urethritis. 
It  must  be  made  negative. 

II.  Sexual  System. 

GONOCOCCAL  VULVITIS. 

Significance. — Significance  is  its  common  and  primary  occurrence 
through  direct  contact  and  with  the  penis  and  less  common  by  descend- 
ing infection  from  cervix  and  vagina. 

Varieties. — ^The  varieties  are  acute,  subacute  and  chronic  and  the 
gonococcus  of  Neisser  is  the  etiology  in  pure  or  mixed  culture.  The 
gross  pathology  modifies  with  the  acute,  declining  and  chronic  period 
and  follows  the  general  character  of  suppurative  dermatitis  with  such 
temporary  lesions  in  the  mild  cases  as  congestion,  desquamation  and 
discharge  laden  with  the  gonococcus.  The  deeper  inflammation 
produces  ulceration  and  crusts  with  less  general  exudate  and  fewer 
organisms  and  the  permanent  lesions  pass  into  chronic  dermatitis 
and  condylomata  acuminata.  Fofliculitis  of  the  hair  on  the  skin  sur- 
face is  common.  The  associated  lesions  are  those  m  the  urethra, 
vagina,  cervix  and  vulvovaginal  glands.  The  minute  pathology  shows 
the  common  features  of  hyperemia,  diapedesis,  exfoliation,  pus-for- 
mation which  may  be  increased  to  ulcers,  scabs  and  papillomata. 

Symptoms. — Symptoms  are  acute  and  chronic,  local  and  systemic, 
subjective  and  objective. 

1  Treatise  of  the  Diseases  of  Women,  1SS9,  p.  886. 

2  In  Kelly  and  Noble,  Gynecology  and  Abdominal  Surgery.  1907,  i,  451. 

3  Jour.  Missouri  State  Med.  Assn.,  November,  1912,  p.  137. 


536  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

Acute  vulvitis  fulfils  the  t^'pe  of  donnatitis  with  folliculitis  of  the 
hair  modified  by  tlie  coexisting  urethritis,  Nagiuitis  and  vestibular 
adenitis.  The  circulatory  signs  are  congestion,  hyperemia,  edema  and 
hifiltration;  the  sensory  signs  are  discomfort  and  pain,  and  the  func- 
tional disturbances  are  frequency  of  m'ination  (more  apt  to  be  due  to 
the  urethritis)  and  discharge.    Gonococci  are  usually  abundant. 

The  subjective  and  objective  systemic  symptoms  may  be  slight  or 
absent  but  in  the  average  case  are  those  of  septic  process — chill  or 
chilluiess,  fever,  prostration  and  the  like.  The  subjective  local  symp- 
toms are  sensory  and  functional  and  during  the  invasion  are  discom- 
fort increasing  to  pain  and  a  discharge  Avhich  is  first  mucous  and 
scanty,  tlien  with  establishment  copious  and  purulent,  especially  from 
the  inner  surface  of  the  vulva. 

The  objective  local  s;>Tnptoms  are  hj^Deremia,  edema  and  irritation 
about  the  labia,  fourchette,  hymen  or  its  remnants,  marking  the 
invasion.  Tenderness  and  discharge  then  appear,  at  first  scanty  and 
mucous,  then  purulent  and,  still  later,  folliculitis  of  the  skin  surface. 
Establishment  reveals  edema,  infiltration,  free  pus,  crusts  and  ulcers, 
fissures  and  cracks.  The  termination  offers  subsidence  of  circulatory 
and  then  sensory  disturbance,  urination  becomes  normal,  discharge 
decreases  and  in  the  cleanly  crusts  never  appear  or  disappear  under 
proper  toilet.  Neglected  cases  continue  to  have  eczema,  adenitis  and 
condylomata,  and  many  develop  typically  chronic  relapsing  lesion. 

Chronic  vulvitis  is  characterized  chiefly  by  persistent  and  relapsing 
dermatitis  and  eczema  with  frequent  follicular  abscesses  of  the  hairy 
surface.  These  conditions  are  not  often  seen  in  cleanly  patients  but  are 
common  in  outpatient  department  subjects. 

Diagnosis. — The  elements  of  the  acute  and  chronic  lesions  vary. 

The  acute  \iilvitis  is  verj^  easily  recognized  from  the  congestion, 
infiltration  and  discharge  and  accompanying  gonococcal  infections  in 
the  urethra  and  other  sexual  organs.  The  gonococcus  is  often  obtained 
from  the  folds  of  the  vulva  and  the  contents  of  glands  after  expression. 
The  hair  follicles  will  sometimes  yield  specimens. 

Chronic  \iilvitis  is  also  easily  diagnosed  from  the  relapses  of  der- 
matitis, folliculitis,  crusts  and  fissures  and  the  recovery  of  the  gono- 
coccus in  other  foci  and  lesions  of  the  disease. 

In  all  cases  smear  and  culture  should  be  made  and  in  the  severe  cases, 
especially  with  other  complications,  the  blood  test  is  warranted.  A 
single  negative  report  must  be  rendered  final  by  securing  a  consistent 
series  of  negative  reports. 

Treatment. — Examinations  for  lesions  above  the  vulva  are  the  first 
step  in  prophylaxis  because  their  discharge  is  usually  the  source  of  the 
vulvitis.  Hot,  long  antiseptic  douches  taken  in  bed  lying  down,  such  as 
potassimn  permanganate  or  bichlorid  of  mercury  1  in  5000,  followed 
by  a  light  tampon,  will  keep  the  vulva  free  of  discharge  from  the 
vagina  and  uterus,  as  examples.  The  eyes  demand  special  attention 
because  the  scratching,  rubbing  and  dressing  of  the  vulva  due  to  the 
itching  and  the  discharge  infect  the  hands.    There  must  be  no  inter- 


GONOCOCCAL  VULVITIS  537 

course  at  all,  or  at  any  rate  durinj^  the  acute  stages,  and  until  the  dis- 
charge is  reduced  to  very  little.  If  coitus  cannot  be  prevented,  then  full 
precautions  must  be  followed  by  both  the  male  and  the  female.  Care 
of  the  bed  and  personal  clothing  is  important  an<l  stains  should  be 
soaked  in  the  solvents  and  not  coagulants  of  pus,  followed  by  soak- 
ing in  antiseptic  solution  and  then  by  boiling  and  laundering.  Thus 
mediate  infection  is  avoided.  The  abortive  treatment  is  similar  to  that 
described  in  this  subject  in  the  male  on  page  47.  The  best  means  is 
painting  the  parts  several  times  a  day  with  silver  nitrate  solution  so 
mild  as  not  to  damage  the  surface  and  thus  invite  rapid  extension  and 
deep  penetration.  One  per  cent,  is  probably  sufficient  if  thoroughly 
and  frequently  applied.    Mild,  moist  antiseptic  dressings  are  helj^ful. 

Particular  notice  is  given  to  management  in  Chapter  IX  on  General 
Principles  of  Treatment  on  page  483. 

The  physical  measures  are  chiefly  hydrotherapeutic.  Douches  and 
irrigations  come  first.  They  should  be  taken  in  bed  on  a  pan.  A 
pitcherful  of  hot  solution  is  poured  on  while  the  labia  are  separated  and 
cleansing  douches  of  normal  salt  solution  followed  by  gentle  mopping 
of  the  surfaces  until  free  of  visible  pus;  then  come  the  medicated 
douches.  These  may  contain  almost  any  antiseptic  according  to 
personal  observation,  such  as:  bichlorid  of  mercury  1  in  10,000  to  5000, 
potassium  permanganate  1  in  8000  to  2000,  carbolic  acid  2  to  5  in  100, 
antipyrin  3  to  5  in  100.  The  best  of  all  is  nitrate  of  silver  in  nonirritat- 
ing  strength,  which  for  the  normal  and  modified  skin  of  the  vulva 
would  be  1  in  500  to  250,  as  a  douche  and  much  stronger  as  a  light  appli- 
cation. The  newer  silver  salts,  such  as  argyrol  10  to  20  per  cent.,  and 
protargol  5  to  10  per  cent.,  are  of  value.  Excess  of  fluid  on  the  parts 
had  best  be  mopped  dry  after  the  douches.  Attention  to  the  vagina  is 
part  of  this  treatment.  Hot  sitting  baths  and  body  baths  are  not  only 
cleanly  but  reduce  the  congestion  and  pain.  The  parts  should  be  care- 
fully dried  after  such  baths  to  avoid  eczema  of  the  already-invaded 
skin. 

The  medicinal  measures  in  the  acute  stages  are  primarily  those  of 
the  gonococcal  acute  infection.  By  systemic  administration,  sedatives 
may  be  given  for  the  itching  and  pain  and  urinary  diluents  and  anti- 
septics for  the  ardor  and  irritation.  Serumtherapy  is  of  no  value  except 
as  indirect  benefit  may  arise  through  its  influence  on  the  disease  as  a 
whole  and  even  this  result  does  not  come  in  the  acute  period.  By  local 
application  lead  and  opium  wash  and  mild  astringents,  such  as  lead- 
water  mixed  with  alum,  will  reduce  the  discomfort,  edema  and  exudate. 
The  douches  and  irrigations  have  been  described  under  hydrotherapy 
in  the  preceding  paragraph,  because  their  heat  is  almost  as  important 
as  their  antiseptics. 

In  the  chronic  stage  the  systemic  treatment  is  that  of  the  gonococcal 
infection  as  described  for  the  male  on  page  274,  and  the  local  appli- 
cations become  the  stronger  astringents  and  even  the  mild  caustics  for 
the  excoriations,  erosions  and  ulcers.  Folliculitis  requires  pulling  the 
hair  out  and  touching  the  pockets  with  tinctm-e  of  iodin.    Itching  is 


53S  GOXOCOCCAL  IXFECriOX  IX  THE  FEMALE 

benefited  by  tlie  standard  anti])ruritics.  such  as  carbolic  salve  2  to  5 
per  cent.,  or  antii)yrin  sahe  '2  to  o  per  cent.  Dusting  powders  of  mild 
antiseptic,  protective  and  dryin<;  powder  are  good.  Thymoliodid,  bis- 
muth subgallate,  zinc  oxid  and  boric  acid  are  usually  and  ^•ariously 
combined  for  this  purpose.  The  moisture  must  not  be  allowed  to  cake 
the  jiowder  upon  the  i)arts.  If  the  skin  is  dry,  then  softening  and 
stinuilating  ointments  are  good,  such  as  zinc  oxid  ointment  mixed  with 
2,  5  or  10  per  cent,  of  ichthyol. 

The  surgical  measures  are  nonoperative  and  operative.  In  the 
former  group  belong  the  dressings  between  the  labia,  of  cotton  or  gauze 
but  not  such  as  to  check  back  the  Aaginal  <lischarge.  They  nuist  not 
irritate  the  surfaces  in  the  acute  stage  and  in  the  chronic  period  they 
likewise  absorb  the  pus  and  promote  cleanliness.  Frequent  changers 
and  burning  of  the  dressings  are  essential.  Other  nonoperative  means 
are  already  mentioned  under  (Gonococcal  Acute  Urethritis  on  page  533. 
Strictly  speaking  there  is  no  operative  work  except  the  curetting  of 
deej)  ulcers  and  the  incision  and  cauterization  of  the  larger  follicles. 

Aftertreatment. — Relapses  due  to  discharges  from  above  should  be 
prevented  in  the  immediate  aftertreatment  and  full  freedom  of  the 
skin  from  foci  of  infection  in  the  follicles  is  the  remote  aftercare. 

Cure. — In  the  three  senses  of  pathologic,  bacteriologic  and  symptom- 
atic relief  vulvitis  is  always  cured.    It  rarely  affects  the  blood  test  at  all. 

GONOCOCCAL  VAGINITIS. 

Significance. — As  the  vagina  is  essentially  the  organ  of  copulation 
it  is  invariai)ly  infected  primarily  if  penetration  has  been  complete,  but 
secondarily  if  the  act  has  been  incomplete  and  the  urethra  and  vulva 
suffer  first. 

Varieties. — The  varieties  are  nongonococcal  and  gonococcal,  acute 
and  chronic,  complicated  and  uncomplicated.  The  nongonococcal 
varieties  have  the  same  causes,  course,  pathology,  symptoms,  termi- 
nation, diagnosis  and  treatment  as  the  analogous  infections  in  other 
parts  of  the  urinogenital  tract  and  closely  imitate  the  gonococcal  which, 
according  to  the  rule  of  this  work,  is  taken  as  the  type. 

Pathology. — The  pathology  is  in  a  degree  determined  macroscopically 
by  the  age  of  the  victim  and  the  period  of  the  disease.  In  sexual  life 
the  lining  of  the  vagina  is  squamous  epithelium  and  closely  analogous 
to  the  skin  and  much  more  resistant  than  in  the  early  and  late  periods 
of  life,  hence  acute  lesions  are  relatively  much  less  commonly  noted 
than  subacute  and  chronic.  In  infancy  and  childhood  the  greater 
delicacy  of  the  mucosa  and  the  absence  of  a  firm  lining  are  invitations 
to  great  acti\'ity  of  infection,  and  in  advanced  age  senile  atrophy  lowers 
the  resistance  and  enhances  the  inflammatory  activity.  For  these 
reasons  the  acute  manifestations  predominate  at  these  ages.  The 
period  of  disease  is  of  importance  in  that  the  more  active  the  process 
the  more  intense  the  pathology.  The  temporary  lesions  of  the  average 
case  are  hyperemia,  loss  of  epithelia,  pus,  gonococci,  round-cell  infil- 


aONOCOCCAL   VAaiNITIf<  539 

tratioii,  extension  until  the  whole  cavity  of"  the  vagina  is  involved, 
followed  by  deeper  inflammation.  Superficial  erosions  and  glan(]ular 
disease  are  both  common.  vSmall,  sometimes  larger  ulcers  with  glandular 
involvement  of  extensive  character  and  even  verrucous  f;hanges  are 
seen  and  the  permanent  lesions  are  the  thickenings  of  the  mucosa,  the 
discharge,  the  glandular  changes  and  cicatrices  of  ulcers.  The  micro- 
scopic features  are  vascular  engorgement,  epithelial  loss,  cellular 
infiltration,  cellular  substitution,  pus,  superficial  or  deep  ulceration, 
involvement  of  the  glandules,  penetration  ,of  infection  imtil  all  coats 
of  the  canal  are  involved  with  the  thickenings,  persistent  discharge 
and  damage  or  destruction  of  the  glands.  The  associated  lesions  are 
due  to  gonococci  in  other  parts  of  the  urinogenital  tract  and  the  compli- 
cating lesions  belong  to  the  urinary  and  the  extragenital  group  as 
already  stated. 

Symptoms. — The  symptomatology  is  acute,  subacute  and  chronic, 
subjective  and  objective,  local  and  systemic.  The  chronic  stage  is  the 
one  most  commonly  seen  because  the  acute  and  subacute  periods  are 
always  associated  with  lesions  of  the  same  activity  but  of  far  greater 
subjective  s\Tmptoms  than  the  vaginitis,  which  is  therefore  often 
largely  masked  and  attracts  comparatively  little  attention  by  the 
patient.  Children  and  the  aged  have  acute  symptoms  and  adults 
subacute  and  chronic  symptoms  in  predominance. 

Gonococcal  acute  vaginitis  has  sensory,  functional  and  exudative 
manifestations  in  its  subjective  local  symptoms.  During  the  invasion 
of  mild  degree,  all  symptoms  are  progressive  from  those.  The  sensa- 
tions are  those  of  heat,  pain,  soreness  and  foreign  body.  They  are 
often  referred  to  the  perineum,  vulva  or  rectum  rather  than  the  vagina 
itself.  Motion,  active  in  walking,  or  passive  in  riding,  increase  the  pain 
but  rest  quiets  it.  The  discharge  is  scanty  and  watery,  exactly  like  that 
from  the  urethra  and  rapidly  becomes  mucopurulent,  rather  thick 
and  tenacious.  The  functional  disorder  is  urinary,  and  comprises 
frequency  and  pain  during  micturition,  but  is  more  often  due  to  the 
associated  urethrovulvitis  than  to  the  vaginitis  itself.  Ulceration  and 
intense  inflammation  cause  vaginismus  and  vaginodynia.  Likewise 
irritation  within  the  vagina  may  cause  slight  rectal  disturbance  and 
even  painful  defecation.  In  the  establishment  the  pain  and  allied 
s^miptoms  are  greatly  intensified  and  increased.  The  discharge  is 
copious,  purulent,  of  green  or  yellow  hue,  occasionally  hemorrhagic 
and  often  excoriating  to  the  vulva  and  thighs. 

The  objective  local  symptoms  are  sensory,  circulatory,  exudative 
and  must  be  distinguished  from  the  signs  of  gonococcal  disease  in 
and  about  the  urethra  and  wXysi  and  the  parts  must  be  examined 
systematically  from  one  to  the  other.  The  h^TQen  or  its  remnant 
is  red,  puffy  and  covered  with  pus,  which  is  seen  to  come  from 
above  after  the  vulva  and  h\inen  have  been  wiped  clean.  The  lin- 
ing of  the  vagina  is  very  h^-peremic,  hot,  tender  and  pulsating,  and 
the  discharge  is  free  and  purulent,  as  described  in  the  preceding 
paragraph.    The  crypts  and  glands  of  the  vagina  behave  much  as  do 


540  GOXOCOCCAL  INFECTIOX  IX  THE  FEMALE 

those  of  the  urethra,  some  are  in  a  state  of  indolent  discharge  and  otliers 
form  minnte  abscesses  "with  cU>sed  thicts  and  otliers  which  have 
ruptured  may  be  tiny,  f;a])iug  pockets.  Ulceration,  superficial  or  deej), 
may  be  scattered  over  the  siu-face.  The  cer^•ix  is  regularly  found  to  be 
invaded,  if  the  vaginitis  is  well  established,  and  complications  may  be 
present  in  the  form  of  lym])hadenitis,  endometritis,  salpingitis,  i)eri- 
tonitis  and  systemic  absori)tion. 

The  subjective  and  objective  systemic  symptoms  are  absent  unless 
the  case  is  luuisually  intense  or  has  complications  leading  to  absorption. 
They  are  then  chill  or  chilliness,  fever,  anorexia,  vomiting,  diarrhea, 
malaise,  prostration  and  tliose  symptoins  which  always  go  with  septic 
invasion.  It  is  doubtful  if  such  a  picture  may  be  drawn  by  the  vaginitis 
alone  as  much  as  by  the  more  severe  associated  lesions. 

The  termination  is  that  the  mild  cases  subside  with  no  sequels,  pro- 
vided the  cervix  above  has  not  become  involved  and  is,  therefore,  not 
a  source  of  constant  discharge  of  pus  into  the  colpos.  These  are,  there- 
fore, cases  of  true  gonococcal  vulvovaginitis  without  extension.  The 
average  case,  however,  is  more  severe,  accompanied  by  extension  into 
the  cervix  and  often  uterus  and  the  acute  stages  are  regularly  followed 
by  one  or  more  forms  of  chronic  vaginitis  and  its  sequels,  which  may 
persist  for  many  years  and  even  defy  relief  in  any  adecjuate  degree. 

Gonococcal  chronic  vaginitis  is  the  form  most  commonly  seen,  for 
the  reason  already  stated.  The  chief  subjective  complaint  is  that  of 
the  discharge,  which  is  slow,  indolent  and  persistent,  or  variable  with 
intermissions,  relapses  and  exacerbations,  often  copious,  less  commonly 
scanty  and  usually  foul  smelling  and  irritating  to  the  skin  so  that  the 
woman  has  eczema  of  the  external  genitals  and  thighs.  The  objective 
signs  are  those  of  a  mucosa  in  chronic  inflammation,  thickened,  exfoliat- 
ing, sometimes  ulcerating  and  its  glands  involved  as  persistently  dis- 
charging pockets  or  as  abscesses  newly  formed  or  recently  ruptured 
and  appearing  as  sinuses  or  fistulse.  Signs  of  deeper  inflammation 
involving  the  wall  of  the  vagina  are  sometimes  present. 

Granular  chronic  vaginitis  has  been  described  by  Finger^  as  consist- 
ing of  numerous  red  and  thick  granules  variously  but  usually  numer- 
ously distributed  over  the  Uniiig,  gi^'ing  it  a  rough  and  granular  feeling 
and  appearance  and  causing  a  rather  characteristic  discharge.  Papil- 
lomata  or  condylomata  are  similarly  seen  within  the  cavity  of  the 
vagina  and  may  arise  from  the  constant  irritation  of  cervical  discharge. 
Bumm-  is  convinced  that  the  constant  chemical  irritation  of  cervical 
discharge  is  a  more  active  cause  of  chronic  vaginitis  than  gonococci 
or  other  infecting  organisms.  Ulcers,  cracks  and  fissures  in  and  about 
the  vagina  may  act  exactly  as  anal  fissure  and  cause  vaginismus  and 
vaginodynia  of  active  degree  and  obstinate  character. 

Diagnosis. — The  elements  vary  with  the  acute  and  chronic  forms. 

Gonococcal  acute  vaginitis  is  not  difficult  of  recognition  when 
typical.    The  history  of  acute  cases  shows  focal  congestion,  irritation 

'  Die  Blennorrhce  d.  Sexualorgane,  1901,  5th  ed.,  p.  359. 

*  According  to  Menge:  Handbuch  der  Geschlechtskrankheiten,  Vienna,  1910. 


GONOCOCCAL  VAGINITIS  541 

and  discharge  incident  upon  and  infecting  coitus  and  thf;  subjective 
symptoms  continue  these  early  signs  of  invasion  to  the  fif>rid  flegree 
of  the  estabHshment.  During  the  corresponding  periods  objective 
signs  must  prove  that  the  disease  is  in  the  vagina  anrl  not  in  the  vulva 
as  bathed  with  pus  from  above  or  in  the  cervix  as  discharging  pus  from 
above.  The  hyperemia,  discharge,  glandular  involvement  and  tender- 
ness with  occasional  ulcers  complete  the  examination.  There  are  always 
signs  of  gonococci  in  the  urethra,  vestibular  glands  and  cervix  which 
are  corroborative  evidence.  Laboratory  specimens  must  be  secured 
from  the  wall  of  the  canal  and  especially  from  the  mucous  crypts, 
sinuses  or  fistulse  in  order  to  prove  that  the  infection  is  from  the  vagina 
and  not  from  the  cervix  above  it.  Schwartz's  or  Schultze's  method^ 
consists  in  thorough  cleansing  of  the  vagina  and  vulva  followed  by 
careful  packing  of  the  fornices  and  about  the  cervix  so  that  discharge 
from  the  latter  cannot  for  many  hours  contaminate  the  vagina.  Such 
a  technic  is  reasonably  certain  to  eliminate  discharge  from  above  and 
to  isolate  that  from  the  colpos  for  the  necessary  specimens.  In  all 
cases  smears  and  culture  must  be  made  and  expert  opinion  consulted. 
The  gonococcal  complement  fixation  test  is  in  severe  and  extensive 
cases  worth  while  and  will  prove  the  nature  of  the  infection  as  a  whole 
but  not  as  of  any  particular  portion  of  the  urinogenital  tract.  The 
diagnosis  of  colpitis  must  delimit  extent  and  determine  severity, 
as  far  as  possible.  As  a  rule,  the  whole  vagina  is  infected  but  some 
portions  more  severely  than  others.  The  posterior  cul-de-sac  is  a  very 
active  focus  whenever  the  cervix  is  also  involved.  Whether  or  not  the 
vaginitis  is  primary  or  secondary  is  another  diagnostic  essential,  so 
that  urethra,  vulva  and  cervix  must  all  come  under  the  diagnostic 
study.  Treatment  is  of  value  in  the  diagnosis  only  as  it  eliminates  the 
other  sources  of  gonococcal  pus,  leaving  behind  various  foci  in  the  vagina 
whose  typical  character  at  once  becomes  apparent  and  easy  of  proof. 

In  gonococcal  chronic  vaginitis  all  the  thickenings  of  the  mucosa, 
in  zones  variously  distributed,  the  glandular  indurations  when  the 
ducts  were  not  occluded  and  the  glandular  sinuses  and  fistula  when 
the  ducts  were  occluded  and  abscesses  formed  and  ruptured  are  the 
pathognomonic  signs. 

Differential  Diagnosis  must  distinguish  gonococcal  vaginitis  from 
that  due  to  traumatism,  chemical  irritation,  simple  infections  and 
excoriating  discharges  from  ulcers  and  neoplasms,  by  the  followmg 
salient  data: 

Traumatic  differs  from  gonococcal  vaginitis  m  havmg  the  history  of 
instrumentation,  tamponade,  packing  and  pessaries  all  more  or  less 
improperly  done  or  used.  Hot  or  rough  mstruments  forcibly  inserted, 
tampons  and  packing  uncomfortably  placed  or  retained  until  sodden 
with  decomposing  mucus  and  pessaries  improperly  fitted  or  placed 

1  Quoted  without  a  reference  by  Norris,  Gonorrhea  in  Women,  1913,  p.  218.  No  such 
"method  of  Schultze"  seems  to  exist  in  Uterature,  but  E.  Schwartz,  Die  gonorrhoische 
Infektion  beim  Weibe,  Samml.  klin.  Vort.,  1886,  No.  279,  Gynakologie  No.  5-1-76, 
describes  much  the  same  method. 


542  GONOCOCCAL  IXFECTIOX  IN  THE  FEMALE 

are  all  factors  of  a  vajiiuitis  \vhic'h  is  usually  niikl,  brief  and  without 
patliogenic  organisms  of  any  kind.  The  subjective  and  objective  signs 
are  those  of  a  catarrhal  lesion  and  the  laboratory  test  is  bereft  of  any 
ini})ortant  elements,  ^^ithdra^val  of  the  cause,  simi)le  cleansing  and 
mild  stimulating  treatment  by  their  promi)t  cure  prove  the  case. 

Chemical  differs  froiti  gonococcal  mginitis  in  its  history  of  strong 
douche  or  applications,  followed  almost  instantly  by  the  inflammation 
and  in  the  absence  of  infecting  intercourse.  It  is  essentially  a  traumatic 
vaginitis  in  that  su])erficial  destruction  of  the  nnicosa  is  an  injury 
and  its  features  duplicate  the  character  but  augment  the  degree  of 
traumatic  vaginitis  just  described. 

Infections  differs  from  gonococcal  vaginitis  in  its  history  of  unclean 
habits  and  the  presence  of  fecal  and  urinary  dei)osits  around  the  vulva 
and  vagina  or  in  the  history  of  diphtheria  ])r()^•i(ling  the  Klebs- 
Loeffler  bacillus,  or  of  dysentery  giving  the  Bacillus  coli  or  of  abscesses 
about  the  rectum  and  uterus  ruptured  into  the  vagina  discharging  the 
pyogenic  organisms,  such  as  the  streptococcus  and  sta])hylococcus. 
Fistule  between  the  vagina  and  the  bladder  or  rectum  or  both  belong 
to  this  category.  The  subjecti^'e  and  ()bjecti\"e  symptoms  are  usually 
characteristic  and  traceable  to  the  underlying  cause  and  the  laboratory 
will  readily  isolate  the  organisms  other  than  the  gonococcus.  A  nega- 
tive complement  fixation  test  in  complicated  cases  is  valuable.  The 
caution  in  these  cases  is  that  they  are  sometimes  engrafted  on  cured 
gonococcal  lesions  rendering  the  distinction  not  only  difficult  but 
sometimes  impossible. 

Ulcerative  and  neoplastic  differ  from  gonococcal  vaginitis  in  the  history 
often  of  indefinite  lancinating  pains  with  hemorrhagic  staining  followed 
by  the  vaginitis,  so  that  the  w4iole  picture  is  one  of  an  antecedent  with 
positive  symptoms,  such  as  cancerous  or  other  ulcer  of  the  cervix  or  the 
ulcers  seen  in  the  third  degree  of  prolapse.  Typical  subjective  symp- 
toms and  objective  symptoms  are  easy  of  demonstration  and  sections 
of  tissue  for  the  laboratory  and  specimens  of  the  discharge  in  smear  and 
culture  and  the  gonococcal  complement  fixation  test  are  positive  for 
the  neoplastic  origin  and  negative  for  the  gonococcus.  Anemia  may 
be  a  })rominent  and  early  symptom  of  active  cancer. 

Treatment. — The  general  scheme  of  measures  is  the  same  in  both 
primary  and  secondary  cases,  which  must  be  distinguished  as  noted 
under  diagnosis;  but  the  antecedent  foci  in  the  urethra,  vulva  and 
cervix  must  have  attention.  In  fact,  probably  all  four  regions  are 
diseased  as  part  of  the  one  process  in  almost  all  cases. 

The  prophylaxis  procures  caution  for  the  eyes  and  care  as  to  the 
urethra,  vulva  and  cervix  as  the  starting-points  of  a  vaginitis  in  order 
to  prevent  onset  of  the  latter.  Conversely,  care  of  a  primary  vaginitis 
prevents  involvement  of  any  one  or  all  of  the  other  three  zones.  Indeed 
the  diagnosis  of  the  fact,  progress  and  cure  of  a  gonococcal  colpitis 
bear  on  the  prevention  of  gonococcal  infection  through  family  ties 
toward  children  and  husband  and  social  ties  toward  innocent  or  guilty 
victims. 


GONOCOCCAL   VAGI  NIT  IS  543 

The  abortive  measures,  as  in  man,  rest  on  early  bacteriolo^ic  diag- 
nosis, which  is  difficult  because  many  primary  cases  show  few  symptf)ms 
and  most  secondary  cases  are  marked  by  tfie  foreruruiing  foci.  Tfie 
best  single  abortive  measure  is  to  put  the  woman  under  a  general 
anesthetic  and  then  to  paint  with  10  per  cent,  silver  nitrate  solution  or 
tincture  of  iodin  the  entire  surface  of  the  cervix,  vagina  and  vulva 
while  the  mucosa  is  stretched  free  of  folds  as  far  as  may  f)e.  'J'he 
cervix  is  treated  last  and  with  fresh  swabs.  The  entire  region  should 
be  a  definite  white  and  ten  minutes  should  be  given  for  full  jjenetration. 
Free  solution  had  best  not  stand  in  any  of  the  pockets.  The  posterior 
cul-de-sac  should  receive  most  attention.  Morphin  must  be  given 
to  stop  the  pain  during  the  first  day,  and  the  urine  must  be  kept 
neutral  and  the  bowels  soft,  which  with  rest  in  bed  decreases  irritation. 
Mild  antiseptic  douches  are  begun  as  soon  as  possible.  One  such 
treatment  is  usually  sufficient.  Another  good  abortive  treatment  is  to 
give  antiseptic  douches  every  two  to  four  hours  during  the  waking  part 
of  the  day  and  whenever  not  asleep  at  night.  Potassium  perman- 
ganate is  the  most  easily  procurable  and  efficient.  Reaction  and  further 
extension  of  the  disease  will  follow  douches  which  are  too  strong,  hence 
heat,  frequency,  duration  and  proper  graduation  are  the  secrets  of 
success.  The  first  solution  should  be  1  in  10,000,  gradually  increased 
to  1  in  2000  according  to  result.  Such  douches  should  be  continued 
for  at  least  a  week  and  at  longer  intervals,  two  or  three  daily,  after 
the  gonococci  seem  to  have  disappeared.  Another  less  serviceable 
method  is  to  pass  a  Ferguson  speculiun  and  to  fill  it  with  5  to  25  per 
cent,  argyrol  solution  and  by  slowly  withdrawing  it  permit  the  anti- 
septic to  bathe  all  parts  of  the  vagina.  The  passage  of  the  speculum 
is  the  disadvantage  of  this  treatment,  which  is  best  reserved  as  the 
office  associate  of  the  douches  at  home  during  the  declining  stages. 
The  technic  of  taking  a  douche  is  described  under  medicinal  measures. 
The  vulva  must  be  separately  cleansed  after  each  douche  as  a  pro- 
phylactic step. 

All  the  procedures  of  management  are  embraced  in  Chapter  IX  on 
General  Principles  of  Treatment  on  page  483. 

Curative  Treatment.— The  details  vary  with  the  acute,  subacute  or 
chronic  period  present  and  with  attention  to  the  other  lesions  in  the 
vulva,  urethra  and  cervix. 

The  physical  measures  are  solely  hydrotherapy  in  the  form  of  hot 
and  medicated  douches  and  sitting  and  body  baths.  The  local  measures 
are  the  douches  which  are  given  every  two,  three  or  four  hours  whenever 
awake  and  best  consist  in  a  cleansing  douche  to  remove  the  pus,  fol- 
lowed by  an  antiseptic  douche  to  penetrate  to  the  diseased  foci.  The 
cleansing  douches  apply  to  the  early  stages  when  any  chemical  might 
cause  increase  of  the  disease  and  when  reaction  to  any  local  treatment 
must  be  cautiously  determined.  The  best  are  normal  salt  solution, 
sterile  water,  boric  acid  2  to  4  per  cent,  and  bicarbonate  of  soda  2  to 
4  per  cent. 

The  douche  continues  until  the  retiu-n  in  a  glass  is  free  of  fluid  pus 


544  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

and  contains  only  a  few  shreds.  Later  in  the  early  declining  stage 
antiseptic  douches  may  be  begun  with  very  weak  concentrations, 
slowly  augmenting  and  never  exciting  a  reaction  or  an  increase  in  the 
symptoms  or  disc-harge.  Among  the  ^•ery  best  is  potassimn  perman- 
ganate 1  in  10,000,  advancing  from  1  in  2000.  Norris^  states  that  the 
"A.  B.  C."  powder  is  an  excellent  medicament  in  douches  for  any  form 
of  gonococcal  disease: 

I^ — Acidi  borici 6  ounces   (186  grammes) 

Phcnolis, 

Piilvcris  alumiui  exsiccati aa     1  oiiiico     (31  grammes) 

Olei  gaulthcriaJ 1  dram      (     4  grammes) 

Olei  menthffi  jjiperitse 30  minims  (     2  grammes) 

Mix,  make  a  i^owder  and  mark: 

One  tablespoonful  in  1  gallon  of  hot  water  as  a  douche. 

The  nitrate  of  silver  is  one  of  the  best  drugs  and  the  first  solution 
should  be  1  in  20,000,  gradually  increasing  to  1  in  500.  The  newer 
silver  salts,  of  which  argyrol  and  protagol  are  examples,  are  too  expen- 
sive for  gallon  douches  and  are  therefore  reserved  for  office  instillations 
and  applications.    Findley-  relies  on  formalin  solution  1  in  2000. 

In  the  chronic  indolent  stages  the  stronger  solutions  and  astringents 
become  available.  The  best  are  mixtures  of  alimi  and  sulphate  of  zinc 
in  from  \  to  2  per  cent,  strength  similar  to  or  exactly  like  the  Ultzmann 
fluid  used  for  injections  and  instillations  in  the  male. 

The  technic  of  douching  determines  its  success  and  must  cover  the 
instrimients  and  supplies,  the  fluid,  the  preparation  of  the  patient  and 
the  aftercare.  The  instruments  and  supplies  are  a  four-quart  rubber 
douche-bag,  with  six  feet  of  rubber  tube  and  a  cutoft',  suitably  curved 
and  straight  glass  return  flow  douche  nozzles,  a  douche-pan,  towels 
and  gauze.  Small  bags  give  insufficient  quantity  which  should  be  at 
least  one  gallon.  The  pressure  should  balloon  the  folds  of  the  vagina 
which  less  than  six  feet  of  tube  does  not  permit.  The  nozzles  are  best 
of  glass  for  cleanliness,  should  have  only  side  openings  and  never  an 
end  opening  and  the  pan  should  permit  the  patient  to  lie  upon  it.  The 
towels  protect  the  pan,  the  bed  and  the  person  from  being  soiled  and 
the  gauze  is  wrapped  loosely  about  the  nozzle  just  at  the  vulva  to 
receive  the  spatter  and  divert  it  into  the  pan  as  a  gentle  stream  or 
dripping.  Such  details  make  the  douche  convenient  and  inviting  and 
their  omission  inconvenient  and  annoying.  The  fluid  should  always 
be  mixed  hot  in  a  pitcher.  The  temperature  should  be  115°  F.  with  a 
bath  thermometer  which  will  deliver  110°  to  105°  F.  Powders  and 
concentrated  solutions  should  never  be  dumped  into  the  douche-bag,  in 
which  they  often  gravitate  to  the  bottom  and  reach  the  canal  in  highly 
irritating  form.  From  such  a  pitcherful  of  the  solution  the  bag  is 
fillefl  and  suspended  from  a  convenient  hook.  The  patient  prepares 
herself  by  mopping  the  vulva  as  clean  as  possible,  after  having  removed 
her  underclothing.     She  lies  on  the  bed  and  on  the  douche-pan  and 

'  Loc.  cit.,  p.  219.  *  Diseases  of  Women,  1913,  p.  410. 


GONOCOCCAL  VAGINITIS  545 

then  the  nozzle  is  inserted  to  the  top  of  the  vagina  without  pain  and 
the  gauze  wrapped  loosely  around  it  in  front  of  the  vulva.  When  the 
cutoff  is  open  the  flow  begins  and  continues  until  the  bag  is  empty. 
After  this  the  nozzle  is  removed  from  the  vagina  and  disconnected 
from  the  tube  and  laid  on  a  suitable  piece  of  paper  or  towel.  The 
douche-pan  is  taken  from  the  bed  after  the  patient  has  suitably  dried 
with  the  towels.  When  possible  the  aftercare  consists  in  keeping  the 
patient  in  bed  with  little  movement  for  a  half-hour  so  that  the  medicine 
may  penetrate.  After  this  she  may  move  about  if  ambulant,  wearing  a 
suitable  pad  to  prevent  staining  the  clothes.  Douches  taken  in  the 
bath-tub  or  sitting  over  the  toilet  lose  most  of  their  value.  Douches 
which  consist  of  one  or  two  quarts  of  fluid  are  almost  useless  and  in 
general  it  is  best  to  give  a  cleansing  douche  of  one  gallon  followed  by 
an  antiseptic  douche  of  another  gallon,  whose  temperature  is  almost 
as  important  as  the  drug. 

Sitting  baths  in  the  method  prescribed  for  males  on  page  57  are  of 
great  value  in  decongesting  the  entire  pelvic  area  and  organs  and  body 
baths  are  not  to  be  forgotten  in  the  general  hygiene  of  each  case. 
Of  course  the  face  must  not  be  bathed  during  them  lest  the  eyes  be 
contaminated,  and  scrubbing  of  the  tub  must  never  be  omitted  in 
protection  of  those  who  follow  the  patient. 

The  sterilization  of  instruments  and  supplies  is  important.  Gauze 
and  pads  should  be  dropped  into  paper  bags  and  burned.  Douche 
nozzles  should  be  boiled  and  stored  in  1  in  5000  bichloride  of  mercury 
solution,  along  with  about  12  inches  of  tubing  kept  as  a  connector 
attached  to  the  nozzle  and  then  joined  to  the  tubing  of  the  bag  with  a 
glass  link.  The  pan  and  the  double-bag  should  be  thoroughly  scalded 
and  scrubbed. 

The  medicinal  measures  in  the  acute  stages  comprise  only  the  cleans- 
ing and  solvent  douches  and  in  the  declining  and  chronic  stages  add 
the  antiseptic  douches  already  noted  under  hydrotherapy,  because 
the  heat  and  the  volume  are  important.  In  the  chronic  stage  direct 
applications  to  foci  become  important  and  the  spray  will  reach 
recesses  and  folds  avoided  by  the  swab.  Graduations  of  nitrate  of 
silver  come  first  from  1  to  1000  to  100,  tincture  of  iodin  1  in  250  of  95 
per  cent,  alcohol,  and  equal  parts  of  alcohol  and  water  are  all  good. 
The  solutions  recommended  on  page  66  for  hand  injections,  irriga- 
tions and  instillations  in  the  male  may  be  atomized.  Polak^  uses 
equal  parts  of  picric  acid  and  glycerin  applied  on  a  gauze  tampon 
for  twenty-four  hours  after  thoroughly  cleansing  the  vagina  with 
a  douche,  inserting  the  Ferguson  speculum  and  pouring  one  or  two 
ounces  of  argyrol  solution  into  the  vagina.  Daily  treatments  for  three 
to  five  times  have  given  this  author  wonderful  results.  Through 
the  Ferguson  speculum  the  writer  has  had  good  results  by  filling  its 
proximal  end  with  argyrol  10  to  50  per  cent.,  protargol  5  to  10  per 
cent,  and  silver  nitrate  1  to  5  per  cent,  and  then  slowly  withdrawing 
the  instrmnent,  permitting  the  fluid  to  reach,  bathe  and  penetrate  all 
portions  of  the  wall  made  tense  across  the  opening  in  the  instrument. 

1  Personal  communication  to  the  author. 
35 


546  GOXOCOCCAL  IXFECriOX  FX  THE  FEMALE 

The  vagina  nuist  first  be  thorous;hl\'  (Uniched  and  the  withdrawal  of 
the  speeiihun  must  take  at  least  fifteen  minutes,  whieh  the  patient 
herself  or  the  office  nurse  may  observe. 

The  ulcerations,  abrasions  and  infiltrations  of  the  chronic  stage 
must  be  touched  with  caustic  for  suiierficial  but  not  penetrating 
destruction.  In  fact,  only  active  stimulation  is  desired.  The  author 
prefers  watery  solutions  of  nitrate  of  siher  or  of  acid  nitrate  of  mercury 
from  10  to  nO  per  cent,  strength.  Copper  sulphate  and  zinc  chloride 
are  good  in  5  per  cent,  to  21)  per  cent,  strengths.  Applications  are  made 
every  two  to  five  da>s  and  only  after  the  result  of  one  a])])lication  has 
spent  itself.  Undermined  edges  and  exuberant  spots  haN'c  special 
attention  according  to  reaction  and  healing.  The  tender  epithelial 
sprouts  must  not  be  destroyed  at  subsequent  applications.  The  actual 
or  the  electrocautery  or  the  high-frequency  ciurent  of  Oudin  in  the 
desiccating  or  coagulating  strength  as  described  in  the  soap  test 
under  electrotherapeutics  in  the  male  on  page  501,  may  all  be  lightly 
employed. 

The  medicated  tampon,  after  douching,  is  inserted  and  retained  over 
night  or  for  twenty-four  hours.  Argyrol  25  to  50  per  cent.,  protargol 
5  to  10  per  cent.,  nitrate  of  silver  2  to  5  per  cent.,  ichthyol  and  glycerin 
10  to  25  per  cent.,  picric  acid  and  glycerin  10  to  25  per  cent.,  may  all 
be  tried.  Ointments  and  bougies  are  of  less  service.  The  ointments 
coat  the  surface  with  grease,  which  tends  to  retard  the  exudate  and  to 
prevent  access  of  the  drugs  to  the  lesions. 

Powders,  insufflated  or  applied  on  a  tampon,  are  of  benefit  in  the 
condition  of  relaxed  mucosa  and  thick  discharge.  They  must  be  anti- 
septic, healing  and  astringent,  such  as  equal  parts  of  calomel,  bismuth 
and  boric  acid  or  equal  parts  of  th^nmol  iodic!,  bismuth  and  boric  acid. 
The  powder  is  dusted  into  and  heaped  on  a  cotton  tampon  which  is 
inserted  e\ery  other  day  and  retained  over  night,  always  after  the 
cleansing  and  the  antiseptic  douches.  Systemic  measures  are  s}Tiip- 
tomatic  and  based  on  general  principles  and  common  sense. 

The  surgical  measures  recognize  no  operative  procedures  except  the 
mild  application  of  the  actual  cautery  as  already  noted  and  the  occa- 
sional curetting  of  an  indolent  ulcer  under  a  local  anesthetic.  The 
nonoperative  steps  are  the  dressings,  such  as  tampons  and  vulvar  pads 
and  applications  as  already  described. 

Aftertrcatment. — Careful  observation  by  the  urologist  and  report 
by  the  patient  of  even  moderate  leucorrhea  are  the  immediate  after- 
treatment.  Its  appearance  demands  renewed  attention  in  physical 
and  bacteriologic  examination  and  repeated  treatment  and  resumption 
of  all  personal  and  social  prophylaxis.  After  medication  has  ceased 
through  negati^'e  bacteriologic  tests  the  mucosa  is  benefited  by  normal 
salt  solution  douches,  which  are  the  remote  aftercare  until  the  catarrhal 
tendency  is  gone. 

Cure. — ^The  vaginal  mucosa  is  rarely  deeply  damaged  because  so 
resistant  and  therefore  a  pathological  cure  is  usually  obtained. 
Freedom  from  discharge  originating  in  cervix,  vagina,  urethra  and 


GONOCOCCAL  CERVICITIS  547 

vulva  and  from  other  subjective  symptoms  is  the  symptomatic  cure. 
Most  important  of  all  is  the  bacteriologic  question.  The  woman 
must  be  negative  after  repeated  examinations  in  both  quiescent  and 
stimulated  stages  for  the  gonococcus.  All  prophylaxis  rests  on  this 
absolute  result.  The  gonococcal  complement  fixation  test  is  usually 
absent,  but  should  be  negative  in  a  cure. 

GONOCOCCAL  CERVICITIS. 

Significance. — Significance  is  special  on  the  point  that  direct  contact 
with  the  penis  by  the  cervix  and  immediate  entrance  of  the  semen  or 
pus  into  the  os  make  gonococcal  cervicitis  frequently  primary  but 
occasionally  secondary  by  ascent  of  the  infection  from  the  external 
genitals  and  vagina.  The  diseased  cervix  may  become  by  direct 
continuity  of  the  mucosa  the  source  of  uterine  lesions  but  fortunately 
this  tendency  is  largely  controlled  and  abated  by  such  natural  factors 
as  the  constriction  at  the  internal  os,  the  plug  of  mucus,  the  gravitation 
of  uterine  secretions  downward  and  outward  against  the  direction  of 
ascent  of  the  organisms  and  the  positive  alkalinity  of  the  secretions, 
which  hinders  or  checks  the  growth  of  the  gonococcus  which  is,  on  the 
other  hand,  favored  by  slightly  acid  media.  Complexity  and  delicacy 
of  the  mucosa  render  penetration  and  persistence  of  the  infection  very 
important. 

Varieties. — The  varieties  are  as  just  stated :  as  to  onset,  primary  and 
secondary;  as  to  location,  cervical,  concerning  the  vaginal  portion  and 
substance  of  the  part,  and  endocervical  related  to  the  mucous  lining; 
and  as  to  course,  acute,  subacute  and  chronic,  complicated  and  uncom- 
plicated. The  pavement  epithelium  of  the  portio  vaginalis  renders 
cervicitis  rare,  whereas  the  columnar  cells  of  the  lining  invite  invasion. 

Pathology. — The  pathology  is  subdivided  into  the  varieties  of  acute 
and  chronic  with  much  tendency  toward  the  latter  in  comparative  or 
actual  absence  of  the  former  and  the  essence  is  exudation,  h\'perplasia 
and  metaplasia  of  the  surface  of  the  cervix  or  its  cavity.  The  t^'pical 
lesions  of  gonococcal  attack  occur,  such  as  hyperemia,  exfoliation  and 
then  substitution  of  epithelia,  infiltration  and  glandular  invasion. 
The  temporary  lesions  are  a  rough,  granular  mucosa,  macroscopically, 
red  and  by  increase  of  the  colmnnar  epithelia  of  the  cavity  over  the 
squamous  cells  of  the  portio  vaginalis  the  outer  surface  shows  a 
roughened  granulation  and  the  os  appears  to  be  eroded.  The  glandules 
may  be  seen  to  exude  a  drop  of  pus  or  to  have  developed  cysts.  Slight 
or  deep  erosions  of  surface  are  also  rarely  seen.  The  microscopic 
features  are  vascular  engorgement,  multiplication,  infiltration  and 
substitution  of  epithelia,  erosions,  invasion  of  glands  which  are  either 
crypts  or  compound  racemose  types,  and  gonococci  in  the  glands  as 
final  lurking-places  and  elsewhere  in  or  on  the  mucous  surface.  The 
process  may  go  on  to  resolution  or  become  chronic  and  have  as  per- 
manent lesions  erosions  due  to  the  multiplication  and  spread  of  the 
epithelia  along  the  surface  of  the  mucosa  and  less  commonly  within  the 


548 


GONOCOCCAL  INFECTION  IN  THE  FEMALE 


glands.  A  tendency  to  cellular  substitution  is  seen  so  that  the  squa- 
nious  displaces  the  columnar  epithelium  and  a  redui)lication  of  layers 
of  the  cells  is  evident,  least  commonly  within  the  glands  but  most 
commonly  over  the  surface.  The  glandular  changes  and  periglandular 
deposits  are  often  marked  so  that  the  glands  are  little  pockets  and 
sinuses  or  fistuhe  in  a  bed  of  dense  tissue.  The  associated  lesions  are 
other  proofs  of  gonococcal  disease  in  the  vul\'o\aginal  glands,  endo- 
metriiun,  oviducts,  peritoneum  and  urethra;  Avhile  the  complicating 
lesions  may  be  of  the  extragenital  t>'pe  in  the  system  at  large  or  of  the 
urinary  type  above  the  m-ethra  in  the  bladder,  ureters  and  kidneys. 

Symptoms. — The  symptoms  are  acute,  subacute  and  chronic,  sub- 
jecti\e  and  objective,  local  and  systemic  and  the  invasion  rapidly 
progresses  to  establishment  by  development  of  sjonptoms.  Gono- 
coccal acute  cer^•icitis  or  endocervicitis  has  sensory,  functional  and 


Fig.  125. — Arbor  vitse  appearance  of  cervical  mucosa.  Magnified.  This  fi2:uro 
illustrates  the  gross  anatomical  reasons  why,  when  gonococci  penetrate  the  mucosa  of 
the  cerWx,  they  are  very  difficult  to  eradicate.     (Dudley.') 

exudative  factors  marking  the  subjective  local  symptoms.  The  sensory 
signs  are  rare  in  the  average  case,  absent  in  the  mild  attacks  but  present 
in  intense  invasions,  perhaps  chiefly  due  to  associated  conditions  such 
as  Brettauer-  notes  in  the  lymphatics  of  the  inguinal  and  iliac  regions, 
whose  tenderness  is  the  chief  source  of  pain  and  proof  that  gonococcal 
invasion  rather  than  the  cervix  itself  is  a  source  of  pain.  The  functional 
disorders  are  menstrual  disturbances,  such  as  irregularity  in  time, 
profusion  of  flow  from  the  congestion  and  sometimes  pain  from  the 
congestion  and  obstruction  of  the  edematous  mucosa. 

The  objective  local  symptoms  are  exudative,  sensory,  circulatory 
and  trophic.  The  discharge  consists  of  epithelia,  wdiite  blood  cells, 
pus  and  detritus  all  containing  gonococci  and  often  mixed  with  mucous 

•  Principles  and  Practice  of  Gynecology,  Lea  &  Fcbiger,  Philadelphia,  1913. 
2  Amer.  Jour.  Obst.,  September,  1911,  p.  457. 


GONOCOCCAL  CERVICITIS  549 

strings  especially  in  the  less  acute  invasions  and  in  the  chronic  course. 
The  sensory  elements  are  tenderness  to  the  touch  of  the  speculum  or 
the  finger,  particularly  in  the  invasion  and  if  there  are  erosions  in  the 
chronic  stage.  The  circulatory  signs  are  hyperemia,  swelling  and  edema, 
forming  a  zone  of  redness  about  the  os  which  spreads  into  the  purplish 
surface  of  the  cervix  which  is  often  peppered  with  red  spots  whicrh 
institute  the  trophic  conditions  characterized  by  the  heaping  up  of  the 
columnar  epithelium  within  the  canal  so  that  it  protrudes  at  the  os, 
making  a  red  dimple.  It  might  be  called  the  "bull's-eye  cervix" 
because  the  red  spot  is  the  center  of  the  target  surrounded  by  a  zone 
of  less  redness,  then  by  one  of  peppery  red  spots  and  finally  by  the 
livid  blue  of  the  portio  vaginalis.  Loss  of  substance  as  superficial  or 
deep  ulcers  is  seen  rather  uncommonly  and  prominence  of  the  glands 
as  minute  abscesses  is  often  a  definite  feature  and  leads  to  the  cysts 
of  the  chronic  period.  The  foregoing  picture  is  drawn  by  the  average 
nulliparous  case  while  the  multiparous  woman  with  lacerations  and 
changes  in  the  cervix  adds  these  to  all  that  has  been  described.  The 
lining  of  the  cervix  is  often  prominently  and  extensively  everted  and 
many  of  the  changes  just  described  have  already  occurred  through  the 
influence  of  mechanical  contact  between  the  relatively  rough  vaginal 
surface  which  is  practically  modified  skin  and  the  definitely  delicate 
columnar  epithelium  of  the  cervix  and  through  the  chemical  action  of 
the  a?id  vaginal  secretion  thereon.  When  the  gonococcal  infection 
of  such  a  surface  occurs  its  results  are  apt  to  be  much  more  profound. 

The  subjective  and  objective  systemic  symptoms  are  very  rare  and 
when  they  occur  rest  more  on  the  associated  and  complicating  condi- 
tions than  on  the  disease  itself  within  the  cervix.  Such  lesions  have 
been  specified  under  pathology  and  cause  the  symptoms  always  seen 
in  infections:  chill  or  chilliness,  fever,  anorexia,  nausea  or  vomiting, 
diarrhea  or  constipation,  perspiration  and  malaise  or  prostration — all 
variously  associated  and  related. 

The  termination  in  very  mild  cases  is  a  ciu-e,  almost  spontaneously 
developed;  but  the  average  case  is  much  more  severe  and  may  either 
pass  through  a  catarrhal  period  with  erosions  and  glandular  disease  and 
long-continued  exudate  before  resolution  occurs  or  may  pass  into  the 
chronic  state  with  deep  changes  everj^where  in  the  mucosa  and  unvary- 
ing symptoms. 

Gonococcal  chronic  cervicitis  or  endocervicitis  follows  two  tv-pes, 
the  one  having  persistent  and  rather  stationary  symptoms  and  the 
other  having  exacerbations  and  relapses  of  subacute  and  even  acute 
attacks.  The  subjective  local  s^Tiiptoms  are  sensory,  functional  and 
exudate.  The  sensory  manifestations  are  pain  and  tenderness,  usually 
absent  but  mild  and  indefinite  when  present.  The  fmictional  distress 
is  disordered  menstruation,  irregular  in  time,  altered  in  amount,  inclined 
to  excess  from  the  congestion  and  exfoliation  of  the  mucosa  already 
present.  Such  results  are  less  manifest  in  endocervicitis  than  in  endo- 
metritis. Dyspareunia  is  not  marked  but  ma}^  occur  from  the  erosions 
of  the  cervix  and  from  cysts  of  the  glands  upon  it;  but  sterility  due  to 


550  GONOCOCCAL  INFECTIOX  IX  THE  FEMALE 

epithelial  alterations  and  occlusion  of  the  canal  is  more  common. 
The  exudative  s>inptoms  are  discharge,  connnonly  called  leucorrhea, 
Avhich  is  thick,  stringy  or  Hocculent,  whitish  or  faintly  yellow,  containing 
epithelia,  detritus,  pus  and  gonococci.  Frequent  examinations  may  be 
negative  for  the  organisms  which  may  be  found  under  stimulation  by 
massage  of  the  cervix,  by  very  gentle  curettement  with  a  sterilized 
hairpin  in  the  bite  of  an  artery  clamp,  by  chemical  applications  just 
after  their  acute  reaction  and  after  puncturing  cysts  or  abscesses. 

Relapses  of  chronic  cer\'icitis  to  subacute  or  acute  attacks  are  evi- 
denced by  increased  discharge,  active  menstrual  disorder  and  sometimes 
pain.  They  usually  appear  during  the  disturbance  of  menstruation, 
pregnancy,  ])uerperiuni,  medicinal  api)lications  and  instrumental 
dilatation;  in  other  words,  during  any  disturbance  of  the  parts — func- 
tional and  active  or  therapeutic  and  passive.  The  objective  local 
s>Tnptoms  are  circulatory,  exudative,  functional,  sensory  and  trophic. 
The  circulatory  disorder  is  hyperemia  and  edema,  both  less  than  in 
acute  and  indolent  rather  than  active.  The  exudate  is  usually  less  in 
quantity  than  in  the  acute  form  but  always  much  thicker  and  stringy, 
flocculent  and  very  abundant  in  detritus  and  desquamated  epithelium. 
The  gonococcus  is  frequent,  especially  after  the  stimuli  which  provoke 
the  relapse  or  the  application  of  the  ^'arious  stimuli  already  described, 
both  functional  and  therapeutic.  The  functional  activity  is  exempli- 
fied by  the  glandular  discharge  and  the  formation  of  cysts.  The  normal 
secretion  of  thin,  clear  and  clean  mucus  is  changed  to  thick,  turbid  and 
infected  mucopus  or  even  pus.  The  trophic  changes  are  along  the  line 
of  hypertrophy  of  the  mucosa,  by  multiplication  of  the  cohmmar  cells 
and  by  reduplication  of  their  layers  so  that  the  complexity  of  the  arbor 
vitae  of  the  cervLx  is  increased  and  the  thickened  mucosa  protrudes  at 
the  OS  forming  the  so-called  erosion  and  giving  a  marked  granular 
appearance,  in  contrast  with  the  normal  glossy  hue  of  the  squamous 
epithelia  on  the  portio  vaginalis.  The  consistency  of  the  cervix  is  soft 
from  chronic  congestion  and  these  granulations  are  boggy  so  that 
bleeding  is  easily  produced.  The  sensory  signs  are  pain  and  tenderness 
of  little  moment  but  the  erosions  may  bleed  on  contact  and  the  cysts 
and  sinuses  of  the  glands  may  be  tender. 

The  subjective  and  objective  systemic  s}Tnptoms  of  chronic  endo- 
cervicitis  are  always  lacking  in  the  typical  and  average  case  but  may 
be  present  in  severe  and  complicated  cases.  The  persistent  discharge 
is  a  grave  annoyance  and  may  be  a  drain  on  the  system,  but  to  ascribe 
to  it  alone  all  the  various  functional  and  nervous  disorders  which  women 
having  these  chronic  lesions  suffer  is  a  misapplication  of  objective  data 
because  the  associated  lesions  of  the  uterus,  annexa  and  peritoneum  are 
vastly  more  potent  in  the  production  of  such  conditions. 

The  termination  may  be  a  persistence  of  low-grade  inflammation 
throughout  life  with  little  or  no  change  except  such  as  occur  in  the 
epithelia  having  a  neoplastic  tendency  or  the  inflammation  may  fire 
up  from  time  to  time  in  active  relapses  or  the  glandular  destruction 
may  be  prolific  of  cysts  and  sinuses.    Occasionally  the  inflammation 


GONOCOCCAL  CERVICITIS  551 

itself  subsides,  leaving  behind  it  numerous  changes  in  the  mucosa  more 
or  less  analogous  with  the  same  process  in  the  prostatic  ur(;thra. 

Diagnosis. — Diagnosis  of  both  acute  and  chronic  cervicitis  and  endo- 
cervicitis  is  comparatively  fa(;ile  because  the  acute  period  may  be 
practically  absent  and  merge  into  the  chronic  disease.  In  the  history 
coitus  may  usually  be  proved  with  the  story  of  immediate  discharge 
and  indefinite  abdominal  sensations  or  of  an  early  discharge  at  the 
vulva  and  then  the  vagina  with  obvious  ascent  and  cervical  symptoms 
after  two  or  three  weeks.  Sometimes  infection  of  lover  or  -husband  is 
admitted.  The  subjective  symptoms  are  the  doubtful  pain  and  ten- 
derness in  the  cervix,  and  the  persistent  and  increasing  discharge  and 
the  objective  signs  recognize  the  two  forms  of  those  without  erosions 
and  those  with  erosions  and  eversions  of  the  mucosa,  and  are  obtained 
through  the  speculum  after  cleansing  of  the  vagina.  The  true  "  bull's- 
eye  cervix"  of  the  nullipara  with  the  drop  or  stream  of  pus  exuding 
from  it  in  the  acute  infections,  but  the  granulations,  cysts  and  small 
sinuses  and  general  edema  in  the  chronic  cases.  Search  for  concomitant 
lesions  of  gonococcal  disease  must  be  made  in  the  externalia.  In  the 
multipara  after  lacerations  the  erosions  become  prominent  and  deep 
and  the  engrafted  gonococcal  disease  augments  both  conditions,  so 
that  the  mucosa  appears  rough,  granular,  soft  and  hemorrhagic  in  the 
way  already  described. 

Laboratory  specimens  in  acute  cases  are  redundant  in  the  gono- 
coccus  but  in  the  chronic  cases  must  often  be  repeated  before  a  successful 
result  appears.  Respect  for  the  influence  of  physiologic  hyperemia 
just  before  or  after  menstruation  and  for  that  of  massage  and  caustic 
applications  must  be  had  before  a  negative  conclusion  is  reached.  The 
gonococcal  blood  test  will  usually  be  positive  in  marked  and  compli- 
cated old  cases.  The  treatment  is  an  aid  in  diagnosis  through  noting 
the  value  of  antiseptic  douches  and  applications. 

Differential  Diagnosis. — The  differential  diagnosis  chiefly  concerns 
syphilis  in  the  chancrous  or  secondary  stage,  neoplasm  and  tuberculosis. 

Syphilitic  differs  from  gonococcal  cervicitis  in  its  history  of  intercourse 
followed  by  symptoms  about  three  weeks  later  for  chancrous  cases,  or 
about  nine  or  ten  weeks  after  the  intercourse  or  six  or  seven  weeks 
after  the  first  symptoms,  in  secondary  outbreaks,  during  other  manifes- 
tations of  this  period,  in  any  other  mucosa  and  the  skin.  The  subjec- 
tive symptoms  are  pain  and  tenderness  due  to  the  erosion  of  chancre 
or  the  mucous  patches  which  commonly  bleed  easily.  The  discharge 
is  different  in  quality,  being  usually  scanty  and  mucoserous  or  sero- 
purulent  rather  than  purulent.  Other  primary  or  secondary  lesions 
may  be  complained  of,  about  the  vulva,  mouth  or  anus.  The  objective 
signs  prove  the  presence  of  corroborating  secondary  lesions  and  that 
of  the  chancre  or  patch  on  the  surface,  which  is  rather  easy  unless 
implanted  on  deep  lacerations  and  erosions  after  childbirth.  In  any 
case  gentle  curetting  of  the  lesions  will  produce  the  characteristic  of 
serosanguineous  discharge  containing  the  Treponema  pallidum  or  it 
will  be  found  in  sections  cut  from  the  os  for  the  laboratory  demonstra- 


552  GONOCOCCAL  IXFECTION  IN  THE  FEMALE 

tioii.  \vhicli  adds  also  the  jiositive  Wassermann  test.  Treatment  is  of 
great  value  in  the  diagnosis  because  mercurial  douches  and  tampons 
locally  and  the  newer  arsenical  products,  such  as  salvarsan  and  neo- 
salvarsan  and  the  standard  mercury  and  iodide  treatment  systemically, 
are  so  magical  in  their  results  as  to  prove  the  case. 

Neoplastic  differs  from  gonococcal  cervicitis  in  not  having  a  venereal 
element  in  the  history  unless  the  neoplasm  is  grafted  on  a  chronic 
gonococcal  cervicitis,  which  then  makes  the  distinction  unnecessary 
but  the  recognition  of  the  cancer  as  important;  in  the  subjective 
symptoms  in  being  less  acute  and  less  congestive  but  more  painful  with 
apparently  unknown  cause  and  later  much  more  hyperemic  and  hemor- 
rhagic; in  its  spontaneous  bleeding  as  an  important  factor  and  usually 
denoting  the  ulcerative  stage;  in  its  objective  findings  of  a  hard,  infil- 
trated and  firm  cer^•ix  even  early  in  the  disease  followed  later  by  deep 
ulcerations  and  extension  into  the  lateral  aspect  of  the  cervix  and 
vagina ;  in  its  incorporation  of  the  vagina,  bladder  and  rectimi  in  vary- 
ing and  progressing  degree  as  the  cervix  becomes  fixed;  in  its  lymphatic 
involvement,  which  may  be  felt  sometimes  early  and  always  late 
through  the  vagina  and  rectimi  and  in  advanced  cases  in  the  iliac  and 
sacral  regions;  in  its  systemic  symptoms  of  emaciation  and  anemia 
and  in  its  progressing  coiu"se  and  final  destruction  of  the  patient. 
Sections  of  tissue  taken  from  the  cervix  will  prove  the  cancerous  nature 
and  acti^'ity  of  the  lesion  and  will  distinguish  it  from  the  deposits  of 
long-standing  simple  or  suppiu^ative  inflammation,  and  syphilic  or 
tuberculous  deposits. 

Tuhercidoiis  differs  from  gonococcal  cervicitis  in  being  very  rare  and 
sometimes  in  the  immediate  or  remote  history  of  tuberculosis  else- 
where in  the  body  or  in  the  family  of  the  patient;  in  the  subjective 
complaints  of  pain  and  bleeding  and  in  the  objective  findings  of  tuber- 
cles, bleeding,  and  bacilli  in  the  pus  and  in  fragments  of  tissue  taken 
for  the  laboratory  which  are  likewise  characteristic  of  tuberculous 
activity;  in  its  picture,  in  advanced  cases,  of  tuberculous  anemia  and 
emaciation  and  in  its  frequent  later  deposits  of  the  disease  elsewhere 
in  the  urinogenital  system  or  the  body  at  large.  The  tuberculin  reac- 
tion is  always  positive  but  is  so  commonly  positive  in  dwellers  in  cities 
as  not  to  possess  great  value  unless  corroborated  by  the  other  clinical 
evidence.  Specimens  cut  from  the  cervix  and  sectioned  distinguish  it 
as  tuberculosis  from  cancer  and  syphilis. 

Treatment. — As  in  every  gonococcal  infection  the  hands  of  the 
patients  and  all  utensils  must  be  scrupulously  clean  in  the  prophylaxis 
of  the  patient's  eyes  and  of  children  and  others  with  whom  she  must  have 
contact.  Intercourse  must  be  forbidden  in  the  interests  of  the  husband 
or  other  men.  The  abortive  measures  are  rarely  possible  because  in 
the  strict  sense  cervicitis  is  almost  invariably  secondary  to  vaginitis. 
Very  early  diagnosis  may  reach  the  first  days  of  the  infection  and  make 
the  method  of  Polak  described  by  Norris^  practically  abortive.    With 

1  Loc.  cit.,  p.  226.  Polak,  in  a  personal  communication  to  the  author,  states  that  his 
method  was  described  by  Geis,  Int.  Jour.  Surg.,  July,  1911. 


GONOCOCCAL  CERVICITIS  553 

the  patient  in  the  high  lithotomy  posture,  after  doiiehing  and  drying 
the  vagina  a  Ferguson  specukim  is  inserted  and  partially  filled  with  a 
25  per  cent,  argyrol  solution  as  a  bath  for  the  cervix  for  ten  minutes. 
A  tampon  soaked  in  equal  parts  of  picric  acid  and  glycerin  and 
supported  by  another  lambs'  wool  tampon  is  left  in  the  vagina  for 
twenty-four  hours.  Daily  repetition  of  this  treatment  is  made  for  about 
a  week  and  will  check  many  cases  of  superficial  gonococcal  cervicitis 
without  involvement  of  the  canal.  True  endocervicitis  is  not  benefited 
by  this  measure. 

The  details  of  management  are  fully  described  in  Chapter  IX  on 
General  Principles  of  Treatment  on  page  483. 

Curative  Treatment. — All  technic  is  modified  by  the  acute  and  chronic 
period  of  the  disease.  Most  cases  belong  to  the  latter  category,  and 
permit  the  more  radical  methods  while  only  expectant  treatment  may 
be  employed  in  the  acute  stages.  Primary  cases  are,  as  stated,  rarely 
seen  and  almost  all  appear  after  the  vagina  has  become  involved. 

The  physical  measures  are  naturally  best  in  the  chronic  period  and 
embrace  massage  and  hydrotherapy.  Massage  will  drain  the  crypts 
of  an  indolent  mucosa  and  is  a  good  preliminary  of  mopping  the  thick 
mucus  away  before  applications.  It  is  somewhat  analogous  to  the 
massage  of  the  male  urethra  upon  a  straight  sound  to  evacuate  the 
follicles. 

The  hydrotherapy  is  local  and  general.  The  former  method  must 
not  be  used  just  before,  during,  or  after  the  period,  and  not  while  a 
tampon  or  packing  is  in  the  vagina.  Douches  are  given  morning, 
noon  and  night  in  the  average  case  with  one  added  in  the  severer 
infections.  They  must  be  hot  within  tolerance,  copious  to  at  least 
one  gallon  and  chemically  mild  within  reaction  or  disturbance.  These 
details  are  described  in  the  technic  of  douching  in  vaginitis  on  page  544. 
The  general  hydrotherapy  is  hot  sitting  baths  to  draw  the  blood  from 
the  deep  pelvis  and  body  baths  for  cleanliness  and  similar  stimulation. 

The  medicinal  measures  are  systemic  and  local  and  are  of  greatest 
service  during  the  chronic  rather  than  the  acute  period.  The  systemic 
administration  is  for  the  subsidence  of  any  absorption  and  chiefly  of 
the  associated  lesions,  notably  those  of  the  urethra,  vulva  and  vagina. 
In  the  chronic  stage  the  influence  is  indirect  and  is  aimed  through  tonics 
to  build  up  resistance  and  to  restore  depreciated  health.  Serumtherapy 
may  be  tried  with  little  promise  of  result.  As  in  the  male,  the  serum 
may  be  used  in  the  later  acute  stage  and  the  bacterin  in  the  chronic 
period.    The  details  are  described  under  serumtherapy  on  page  512. 

The  local  medication  is  best  omitted  during  the  ascending  and 
descending  congestion,  usual  three  days  before  and  after  the  menses. 
A  preliminary  essential  is  removal  of  the  slimy  slug  of  mucus  usually 
adherent  in  the  os  externum.  Most  of  the  available  drugs  coagulate 
its  mucopus  or  mucus  forming  a  very  thick  soft  scab  protecting  the 
diseased  epithelium.  An  alkaline  douche  should  be  taken  at  home  of 
either  sodium  bicarbonate,  sodium  biborate  or  normal  salt  solution, 
alone  or  combined  to  soften  the  mucus.    In  the  office  a  speculum  and 


554       GONOCOCCAL  INFECTION  IN  THE  FEMALE 

tenaculum  expose  the  cervix  which  is  sponged  or  sprayed  with  sunihir 
sohitions  and  swabbed  free  of  mucus  with  sterile  cotton  on  probes. 
This  is  su})erficial  external  and  internal  cleansinij  of  the  cervix  as  far 
as  the  OS  interniun,  which  must  not  be  passed.  Injections  are  dangerous 
but  instillations  of  a  few  drops  of  mild  antiseptics  and  caustics  are  of 
^■alue  through  a  syringe  similar  to  the  Bangs  or  Keyes  instruments, 
with  freedom  for  return  flow  so  that  nothing  will  be  carried  into  the 
endometrium.  Swabbing  the  cer\-ix  with  a])j)li('ators  is  perhaps  the 
best  method.  'I'he  cotton  should  be  almost  dri])])ing  so  that  excess 
fluid  will  soak  into  the  folds  and  crypts. 

The  technic  of  swabbing  is  as  important  as  that  of  douching  and 
covers  the  following  details :  After  the  vagina  is  cleansed  with  a  solvent 
douche  a  specuhun  and  tenaculum  have  exposed  the  cervix.  Dilata- 
tion, if  necessary,  is  secured  with  the  Hanks'  sounds  passed  only 
through  the  external  os.  All  surfaces  are  then  dried,  the  posterior 
cul-de-sac  protected  with  gauze,  the  mucus  plug  thoroughly  removed 
and  then  the  swabs  just  dripping  with  the  drug  are  inserted  and  moved 
in  all  directions  excei)t  through  the  internal  os  in  order  to  reach  all 
points  of  the  disease.  The  usual  relative  strengths  and  combinations 
of  standard  drugs  are  preferred.  The  best  are  nitrate  of  silver  5  to  15 
per  cent.,  tincture  of  iodin,  pure  or  half-strength  ichthyol,  potassium 
permanganate  1  in  500  to  1  in  250,  argyrol  25  to  50  per  cent.,  protargol 
10  to  20  per  cent.  Visible  reactions  must  be  had,  such  as  the  white 
stain  of  nitrate  of  silver,  the  brown  of  iodin  and  the  black  of  ichthyol, 
argyrol  or  potassium  permanganate.  Exuberant  granulations  are 
burned  off  with  caustic  strengths.  In  the  catarrhal  stage,  when  infec- 
tion is  absent,  the  astringent  concentrations  are  indicated  in  about  a 
third  strength  or  less  of  the  foregoing  solutions.  Ultzmann's  solution 
as  employed  in  the  male,  in  the  same  or  double  strength,  is  good. 
Repetition  is  better  than  undue  strength  of  application  and  due  time 
must  be  permitted  for  the  formation  and  casting  of  the  superficial 
slough  and  for  healing  of  the  mucosa  before  another  treatment  is  given. 

The  tampon  is  of  value  as  in  vaginitis  and  employed  in  the  same 
manner.  A  thin  mass  of  cotton  is  thoroughly  saturated  with  the  drug 
and  then  wrapped  carefully  about  the  cervix  for  full  absorptive  and 
decongestive  action.  What  might  be  called  counterinoculation  may 
be  tried  with  yeast  or  lactic  acid  bacilli.  Reports  in  literature  are 
contradictory.  The  probabilities  are  that  it  may  succeed  in  some  cases 
and  fail  in  others.  Abraham^  and  Menge^  employed  yeast  in  any  case 
and  Martin''  in  pregnancy.    Watson^  employed  lactic  acid  bacilli. 

The  technic  with  yeast  is  a  clean,  dry  vagina  after  a  normal  salt 
solution  douche  and  the  yeast  powder,  previously  sterilized  or  not, 
is  either  insufflated  into  the  cavity  of  the  vagina  and  cervix  or  applied 
heaped  liberally  on  a  tampon.  Abraham  states  that  he  reinforces  this 
treatment  with  a  glycerin  suppository  rich  in  yeast. 

'  Monats.  f.  Geb.  u.  Gyn.,  vol.  xxxi.  ^  Hand.  d.  Geschlechtskh.,  Vienna,  1910. 

'  Berl.  klin.  Wchnschr.,  1904,  No.  13,  pp.  325  and  329. 
*  British  Med.  Jour.,  January  22,  1910. 


GONOCOCCAL  CERVICITIS  555 

The  Watson  procedure  obtains  whey  by  filtering  sour  skimmed 
milk.  Salts,  lactose,  lactalbumen  and  abundant  lactic  acid  bacilli  are 
in  the  whey,  which  may  be  reinforced  with  powdered  lactic  acid.  Daily 
treatments  with  either  the  yeast  or  the  bacilli  method  are  necessary 
until  the  gonococcus  remains  absent. 

The  author  has  tried  bougies  containing  active  lactic  acid  bacilli 
in  the  male,  in  various  stages  of  gonococcal  urethritis.  '^I'he  results 
seem  to  be  that  the  bougie  as  a  foreign  body  excited  the  urethritis 
more  than  the  lactic  acid  bacilli  destroyed  the  gonococci.  This  is 
rather  the  logical  outcome  because  such  foreign  body  offence  begins 
with  the  moment  of  introduction  of  the  bougie  into  the  inflamed  canal, 
whereas  inoculation  and  growth  of  the  bacilli  upon  the  mucosa  require 
at  least  many  hours.  The  latter  process  is  handicapped  by  such  a 
lapse  of  time.  He  has  long  ago  abandoned  the  method  as  a  virtual 
failure. 

The  surgical  measures  are  nonoperative  and  operative.  Chief  among 
the  former  is  dilatation  of  the  canal  with  the  Hanks  sounds,  as  needed, 
and  already  described.  The  minor  operative  technic  are  incision  and 
cauterization  of  the  nabothian  cysts  when  they  occur  and  the  curette- 
ment  of  unhealthy  granulations  and  cauterization  of  deeper  lesions  in 
Hunner's  method.  Douches  and  tampons  should  always  follow  such 
procedures.  Trachelectomy  is  the  one  major  operation  available  for 
destructive  lesions  in  the  cervix.  For  details  of  this  operation  the 
reader  is  referred  to  works  on  gynecology. 

The  Hunner  technic^  is  selected  for  deep  lesions  with  intractable 
symptoms.  A  speculum,  tenaculum,  thermocautery  or  electrocautery, 
tampons,  gauze  and  dressing  forceps  are  required.  The  patient  is 
prepared  by  douching  and  drying  the  vagina  and  by  securing  the  cervix 
with  the  tenaculum  between  the  blades  of  the  speculum.  General 
anesthesia  is  never  used  and  local  anesthesia  only  when  the  cervix  is 
very  sensitive.  The  Sims'  position  and  speculum  are  best.  The 
cautery  at  dull  red  heat  is  drawn  evenly  along  the  axis  of  the  cervix, 
burning  not  too  deeply  and  not  more  than  2  to  5  mm.  wdth  a  respite 
between  each  stroke,  which  number  a  half-dozen  or  less.  Packing  is 
used  for  bleeding  or  discharge.  Repetition  is  after  three  weeks,  per- 
mitting full  healing  and  restitution  so  far  as  possible.  Ten  sittings  are 
usually  sufficient.  The  method  is  dangerous  except  in  the  hands  of 
an  expert,  because  the  burns  may  readily  be  too  extensive.  A  small 
cervical  drain  attached  to  the  vaginal  gauze  with  the  removal  of  both 
at  the  end  of  twenty-four  hours  is  good  practice. 

Curettement  of  the  cervix  followed  by  the  applications  just  noted 
may  be  done.  It  usually  requires  repetition  every  two  weeks  for 
several  sittings.    As  a  rule  it  is  combined  with  uterine  curettement. 

Aftertreatment. — Gonococcal  cervicitis  in  general  requires  continua- 
tion of  treatment  for  many  weeks.  It  is  of  slow  progress  toward  cure 
and  does  not  suddenly  cease.    There  is  usually  a  catarrhal  afterstage 

1  Jour.  Am.  Med.  Assn.,  January  20,  1906,  p.  191. 


556  GOXOCOCCAL  INFECTION  IN  THE  FEMALE 

which  soniotinios  requires  as  iiuieh  attention  as  tlie  infective  staf2;e. 
In  the  immediate  aftertreatment  there  must  be  no  intercourse  and  the 
siu*geon  must  keep  the  case  under  careful  observation  and  frequent 
bacteriologic  test.  The  remote  aftercare  is  an  occasional  report  to 
the  doctor's  office  with  a  bacteriolofiic  examination.  If  the  woman  is 
married  or  is  livinu:  with  a  man  and  if  she  has  resumed  regular  sexual 
relations  with  hun  without  infecting  him,  then  this  fact  becomes  the 
best  of  all  tests  because  it  is  a  physiological  test. 

Cure. — Gentle  persistent  judicious  measures  with  full  coojxTation 
by  tlie  patient  will  induce  a  cure.  Cervicitis  in  many  of  its  features  is 
analogous  to  })rostatitis  in  the  male.  The  ])athologic  ciu'c  is  often 
secured  and  without  permanent  lesions  except  in  the  crypts,  and  the 
symptomatic  cure  is  usual  in  intelligent  patients.  The  bacteriologic 
cure  nuist  be  absolute  after  repeated  tests  and  may  eml)race  also  the 
hcmologic  tests.  It  may  be  present  although  a  slight  noninfectious 
catarrh  may  persist.  The  woman  must  be  examined  in  the  quiescent 
and  excited  states  as  discussed  in  the  general  subjects  of  prophylaxis, 
and  intercoiu'se  must  not  be  had  until  the  organisms  have  been  con- 
sistently absent  for  at  least  three  examinations  at  long  intervals,  such 
as  monthly.  The  complement  fixation  test  is  im])ortant,  especially 
as  in  the  long  and  severe  cases  it  is  apt  to  be  present.  The  negative 
reaction  is  desu-able. 

GONOCOCCAL  ENDOMETRITIS. 

Significance. — Significance  regards  the  factors  of  extension  and  results 
of  the  disease  within  the  womb.  The  gonococcus  advances  directly 
along  the  mucosa  from  the  cervix  to  the  endometrium  in  severe  cases, 
being  hindered  by  the  narrow  internal  os,  the  plug  of  mucus  and  the 
gravitation  of  the  uterine  mucus  and  other  secretion  outward  against 
the  line  of  attack.  As  in  all  gonococcal  lesions  the  endometriiun  is 
profoundly  altered  in  any  severe  and  in  man}''  average  cases  so  that 
sterility,  dysmenorrhea  and  other  disturbances  of  this  function  are 
seen. 

Varieties. — The  varieties  are  as  to  course  acute,  subacute  and  chronic, 
as  to  organisms  nongonococcal  and  gonococcal  and  as  to  sequels  uncom- 
plicated and  complicated. 

Etiology. — The  etiology  is  in  the  predisposing  factors  anything  which 
contributes  to  uterine  congestion  in  the  form  of  catarrhs,  lacerations, 
displacements,  deformity  and  the  like.  Uterine  disease  secondary  to 
miscarriage  and  abortion  is  a  potent  element,  likewase  physiological 
congestions  of  menstruations  and  puerperimn.  During  menstruation 
the  mucosa  is  congested,  and  the  plug  of  mucus  is  absent  or  free, 
depriving  the  womb  of  its  protection,  and  after  childbirth  or  miscarriage 
the  same  condition  is  present  in  more  pronounced  degree  so  that  an 
old  infection  of  the  cervix  by  lighting  up  or  a  new  infection  may  advance 
into  the  endometrium. 

The  exciting  cause  is  always  the  pus-producing  organisms,  of  which 


GONOCOCCAL  ENDOMETRITIS 


557 


:Cl 


we  are  chiefly  concerned  with  the  gonococcus  althouj^h  the  Strepto- 
coccus and  the  Staphylococcus  pyogenes  are  equally  common  and 
important,  yet  less  usually  sexually  acquired  in  that  they  are  seen 
after  childbirth  and  miscarriage.  Meddlesome  office  instrumentation, 
previously  the  vogue,  may  be  the  indirect  or  direct  cause  of  infection. 
Its  indirect  influence  is  slight 
traumatism  and  removal  of  the 
mucous  plug  permitting  transit 
of  the  gonococcus  and  its  direct 
action  is  transmission  of  germs  on 
the  surface  of  the  instruments 
picked  up  in  the  vagina  or  cervix 
or  already  present  in  the  lower 
parts  of  the  endometrium. 

Pathology.  ■ —  The  pathology 
must  embrace  the  common  acute, 
subacute  and  chronic  nongono- 
coccal and  gonococcal  varieties, 
of  which  the  latter  is  the  type 
for  our  purposes,  and  the  essence 
of  the  process  duplicates  that 
seen  in  all  infections  with  this 
organism  although  the  process 
evolved  by  the  pyogenic  germs 
may  simulate  it  in  every  step  ex- 
cept the  presence  of  the  gono- 
coccus. The  tissues  involved 
are  primarily  the  endometrium 
and  secondarily  the  metrium, 
as  few  severe  cases  escape  with- 
out disease  of  the  uterine  muscu- 
laris. 

Gonococcal  acute  endometritis 
has  circulatory,  exudate  and  tro- 
phic signs  as  its  temporary  lesions 
which  may  restitute  or  go  on  to 
permanent  changes  which  are  the 
rule  in  most  cases,  at  least  in 
portions  of  the  mucosa.  The 
circulatory  conditions  are  en- 
gorgement so  that  macroscopic- 
ally  there  are  redness,  edema 
and  ecchjTnoses,  combined  with 
the  exudative  lesions  of  a  thin,  rather  than  a  thick  mucopurulent  or 
purulent  discharge  bathing  the  surface  and  redundant  with  gonococci. 
The  trophic  elements  are  the  exfoliation  of  epithelia  promoting  a  rough 
granular  surface,  disseminately  or  diffusely.  ^Microscopically  are  the 
minute  hemorrhages,  numerous  red  and  white  blood  cells  and  small 

1  Principles  and  Practice  of  Gynecology,  6th  ed.,  1913. 


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Fig.  126. — Normal  uterine  muco.sa  in  a 
woman,  aged  twenty-five  years.  Four  main 
glands  are  shown.  The  small  cross-sections 
are  branches  of  the  main  gland.  The  glands 
dip  down  to  and  verj^  Uttle  into  the  muscu- 
laris,  40  diameters.  The  fact  that  these 
mucous  glands  are  branched  and  compo\m.d 
and  penetrate  into  the  muscularis  demon- 
strates the  importance  of  gonococcal  in%-a- 
sion.     (Dudley.!) 


558       GONOCOCCAL  INFECTION  IN  THE  FEMALE 

round  cells  invadins;  the  mucosa  in  the  circulatory,  trophic,  glandular 
and  iNTiiphatic  patholojiy.  The  circulatory  chanjjes  present  the 
hx'peremia.  swelling;  and  edema  and  the  dilated  vessels  extending;  into 
the  nuiscle  coat.  The  trophic  clisor{:;anization  is  the  loss  or  multiplica- 
tion of  cells  of  the  epithelium,  superficial  ulcers  and  thickenings  and 
cellular  substitution  shown  in  atypical  size,  form  and  staining  of  the 
elements.  The  glands  may  more  or  less  escape  or  be  ])rofoundly 
changed,  so  that  every  ])ossibility  from  normal,  contracted,  enlarged, 
cyst  and  abscess  cavities  are  seen.  Their  epithelia  are  modified  but 
less  than  on  the  surface  of  the  endometriimi  and  usually  exfoliated 
or  thickened.  The  stroma  of  the  mucosa  is  in\aded  with  white  and 
red  cells,  serum  and  alteration  of  its  essential  cells  and  the  lym])hatics 
passing  into  the  myometrium  are  engorged  with  inflammatory  jiroducts. 

The  permanent  lesions  are  the  same  as  those  produced  by  the  gono- 
coccus  in  every  mucous  membrane  and  are  represented  by  loss,  sub- 
stitution and  contraction  of  epithelia  of  the  glands  and  the  surface 
and  in  more  or  less  persistent  catarrh. 

Gonococcal  chronic  endoinetritis  is  usually  a  positive  degree  of  the 
permanent  lesions  of  acute  endometritis,  having  the  essence  of  chronic 
productive  inflammation,  disseminate  or  diffuse,  so  that  there  are 
thickenings  or  atrophy  or  the  mucosa  may  be  nearly  normal.  Macro- 
scopically  are  unevenness  and  irregularities  of  surface  with  many  poly- 
poid areas  and  granulations,  with  indolent  hyperemia  and  exudation. 
]\Iicroscopically  the  epithelia,  glands,  stroma,  vessels,  I.\Tnphatics  of 
both  the  endometrium  and  myometrium  are  changed.  In  the  super- 
ficial mucosa  are  cellular  loss  in  desquamation  and  ulceration,  multi- 
plication in  thickenings,  granulations  and  polypi  and  substitution  in 
metaplasia — columnar  cells  being  either  atypical  or  displaced  by 
squamous  cells.  The  glandules  are  enlarged,  hAq^ertrophied,  com- 
pressed or  atrophied,  patent  or  occluded  with  cystic  or  abscess  develop- 
ment. Their  epithelia  are  lost,  multiplied  or  substituted  exactly  as  on 
the  siuface  but  in  much  less  degree,  and  secretion  is  absent  or  altered, 
becoming  thick,  mucoserum  filled  with  white  or  red  bloodcells,  des^ 
quamated  epithelia,  detritus  and  pus  in  which  the  gonococcus  may  or 
may  not  be  present.  The  stroma  is  infiltrated  with  red  and  white 
bloodcells  and  small  round  cells  and  often  so  h^q^ertrophied  as  to 
group  the  glandules  abnormally,  crowding  many  together  and  separat- 
ing others.  The  stroma  is  further  modified  by  vascular  hypertrophy 
and  multiplication  extending  even  into  the  muscularis,  which  is  invaded 
in  the  same  way  along  the  course  of  the  bloodvessels  and  lymphvessels, 
constituting  the  early  degree  of  metritis. 

The  associated  lesions  of  both  acute  and  chronic  endometritis  are 
other  gonococcal  foci  in  the  internal  and  external  reproductive  organs, 
especially  metritis,  salpingitis,  ovaritis  and  peritonitis  in  severe  cases, 
and  the  complicating  lesions  are  of  the  systemic  and  urinary  type 
involving  the  urinary  organs  above  the  bladder. 

Symptoms. — The  symptoms  are  acute,  subacute  and  chronic,  sub- 
jecti\e  and  objective,  local  and  systemic  and  vary  with  invasion, 
establishment  and  termination. 


GONOCOCCAL  ENDOMETItlTIH  559 

Gonococcal  acute  endometritis  has  circulatory,  sensory,  exudative 
and  functional  disturbance  in  the  invasion,  which  is  usually  less  marked 
than  in  many  other  gonococcal  lesions.  The  circulatory  excitement 
causes  the  indefinite  weight,  dragging  and  pain  of  the  early  days  and 
is  involved  with  the  exudation  in  the  subjective  local  outbreak.  The 
functional  derangement  of  the  menses  is  that  they  are  checked  or 
decreased,  excited  or  prolonged.  Vaginal  and  cervical  discharge  is 
at  first  decreased  and  then  with  the  establishment  increased  like  that 
from  the  endometrium  and  all  the  other  symptoms.  In  these  respects 
the  discharge  behaves  exactly  like  that  from  the  male  anterior  urethra 
when  the  prostatic  urethra  becomes  involved,  as  already  explained. 
With  the  continuance  of  the  inflammation  menstrual  disorder  is  pro- 
longed or  augmented. 

The  objective  local  signs  are  classed  as  circulatory,  exudative,  sen- 
sory and  functional.  Congestion  of  circulation  enlarges  and  softens 
both  the  body  and  cervix  of  the  uterus  and  commonly  opens  the  os 
externum  so  that  it  gapes  and  is  filled  with  exudate.  The  discharge 
is  thin  and  serous,  differing  from  that  from  the  cervix,  which  is  mucous 
and  stringy.  Admixture  of  the  cervical  and  endometrial  discharge 
is  copious,  moderately  thick  and  somewhat  stringy,  whitish  or  positive 
yellow  according  to  the  mucopus  or  pus  present  and  its  constituents 
are  mucus,  pus,  red  and  white  bloodcells,  epithelia,  detritus  and 
organisms,  notably  the  gonococcus.  Tenderness  is  often  found  in  the 
body,  cervix  and  annexa  of  the  womb  and  the  functional  disturbances 
complained  of  by  the  patient  may  be  corroborated  by  observation. 
Instrumental  examination  of  the  endometrium  is  meddlesome  and 
dangerous  and  no  longer  practised  by  experts. 

The  subjective  and  objective  systemic  symptoms  may  be  absent  in 
mild  cases  but  are  usually  present  and  moderate  or  marked  according 
to  severity.  They  are  those  of  all  septic  and  absorptive  conditions — 
chill  or  chilliness,  anorexia  with  nausea  or  vomiting,  diarrhea  or  con- 
stipation, fever  which  is  usually  moderate  and  always  variable  in  its 
changes,  circulatory  and  respiratory  excitement,  malaise  and  pros- 
tration. 

The  termination  varies  with  severity.  The  mild  cases  may  go  on  to 
practically  complete  anatomical  and  physiological  recovery  but  these 
cases  are  rare  because  the  gonococcus  has  a  locally  destructive  power. 
The  average  severe  case  is  apt  to  pass  into  more  or  less  typical  chronic 
lesions  with  the  symptoms  described  under  chronic  endometritis  and 
the  intense  cases  during  their  acme  or  even  subsidence  may  develop 
extensions  into  the  myometrium,  tubes,  ovaries  and  peritoneal  cavity. 

Gonococcal  Chronic  Endometritis. — This  lesion  is  one  of  grave 
significance  to  the  woman  in  the  anatomy  and  physiology  and,  like 
cervicitis,  to  the  community  in  the  infectiousness  which  it  retains  for 
long  periods.  Its  etiology  is  that  of  a  prolongation  of  an  acute  attack 
or  a  direct  origin  in  a  subacute  or  semichronic  onset.  Either  may 
arise  or  be  associated  with  the  acute  form  exactly  as  has  been  stated. 
Likewise  as  in  the  cervix,  chronic  endometritis  may  have  a  low-grade 


560  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

persistent  or  slowly  progressive  quality  or  numerous  relapses  and 
exacerbations  dependent  on  the  normal  processes  of  menstruation  and 
labor,  or  on  the  accidents  of  miscarria<;e  and  abortion  or  on  meddle- 
some and  septic  instrumentation  or  on  trauma  by  manual  examination. 
Any  of  these  factors  by  producing  hx-peremia  or  breaks  in  the  surface 
of  the  mucosa  open  the  portal  for  entrance  of  the  disease  as  a  relapse, 
exactly  as  a  primary  attack. 

S.Muptoms  arc  as  in  all  cases  subjecti^■e  and  objective,  local  and  sys- 
temic. Exacerbations  ImAe  all  the  elements  of  fresh  acute  outbreaks. 
The  subjective  local  s\Tnptoms  are  exudative,  sensory  and  functional. 
The  discharge  is  the  most  prominent  persistent  and  significant  com- 
plaint. Its  quantity  is  considerably  less  than  in  the  acute  stages  and 
its  quality  is  less  tenacious,  stringy  and  purulent  owing  to  the  mixture 
of  the  endometrial  and  cer\ical  mucus  and  the  gradual  subsidence  of 
the  pm^ulence.  Its  constituents  are  otherwise  the  same:  red  and  white 
bloodcells,  puscells,  epithclia,  detritus  and  organisms  of  which  the 
gonococcus  is  most  important  but  often  very  difficult  to  detect  and  a 
large  nimiber  of  negative  specimens  alone  tend  to  prove  its  absence 
as  shown  mider  diagnosis.  The  sensory  conditions  are  slight  except 
during  an  exacerbation,  when  they  duplicate  those  described  under 
acute  endometritis.  The  functional  derangement  concerns  menstrua- 
tion, impregnation  and  pregnancy.  Any  possible  change  in  menstrua- 
tion is  seen.  Painlessness  may  become  severe  dysmenorrhea.  Scanty 
may  become  profuse,  and  profuse  may  change  to  scanty  or  absent; 
so  tliat  dysmenorrhea,  amenorrhea,  menorrhagia  and  even  metror- 
rhagia are  not  uncommon  as  alterations  of  previously  normal  men- 
struation. Changes  in  the  endometrium  make  impregnation  impossible 
so  that  relative  sterility  is  seen  or  if  conception  occurs  the  same  lesions 
lead  to  abortion. 

The  objective  local  symptoms  relate  to  the  other  sexual  organs  and 
the  peritoneum  and  are  physical,  functional  and  exudative.  Signs  of 
the  gonococcus  are  easily  seen  in  the  urethra,  vulva,  vestibular  glands 
and  cervix^  The  body  of  the  womb  is  enlarged,  softened  from  chronic 
congestion,  somewhat  tender  and  often  altered  in  flexion  and  position. 
If  the  case  has  been  severe,  metritis  is  present  and  augments  these 
othervvise  indefinite  and  variable  signs  and  also  lesions  in  the  annexa 
and  pelvic  peritoneimi  may  offer  abundant  objective  findmgs  in  enlarge- 
ments, deformities  and  adhesions.  The  discharge  has  a  thinner 
consistency,  less  purulence  but  the  same  microscopic  and  bacterio- 
logical findings  as  noted  in  acute  endometritis.  Corroboration  of  com- 
plaints concerning  menstrual  disturbance,  sterility  and  abortion  is 
definite  and  often  easy. 

The  subjective  and  objective  systemic  symptoms  are  usually  lacking 
or  insignificant;  when  present  they  are  more  apt  to  depend  on  extensions 
of  the  disease  into  the  tubes  and  peritoneum  or  on  complications  in 
the  upper  urinary  tract  than  on  the  endometritis  itself. 

The  termination  is  a  very  uncertain  matter.  Anatomical  recovery 
is  probably  never  seen  m  that  portion  of  the  mucosa  and  glands  are 


GONO(JOCCAL  ENDOMETIifTIS  561 

profoundly  changed.  Physiological  rc(;ov(!ry  in  mild  cas(;s  is  sometimes 
observed  but  the  average  chronic  infection  leaves  permanent  changes 
and  persistent  symptoms.  These  may  be  only  a  mild  catarrh  or  a 
relapsing  mucopurulent  or  ])urulent  leucorrhea  or  incurable  dysmenor- 
rhea. The  secjuel  of  sterility  or  frequent  abortion  is  very  important 
and  finally  the  infectiousness  of  the  woman  in  intercourse  is  often  a 
menace  for  many  years. 

Diagnosis. — Diagnosis  of  gonococcal  acute  endometritis  due  to  the  gono- 
coccus  is  usually  not  difficult.  The  history  affords  admission  of  con- 
taminating intercourse  and  the  progress  of  the  disease  from  the  urethra 
and  the  vulva  upward  or  its  appearance  in  these  parts  at  about  the  same 
period.  The  subjective  complaint  is  dragging  pain,  free  discharge  and 
altered  menstruation  combined  with  the  objective  sign  of  an  enlarged 
uterus  and  of  gonococcal  pus  in  the  urethra,  vulva,  vestibular  glands, 
vagina  and  cervix.  The  laboratory  specimen  detects  the  gonococcus  in 
one  or  more  specimens  and  recognizes  the  character  of  the  constituents 
of  the  pus,  especially  the  mucoserum,  as  contrasted  with  the  thick  mucus 
of  the  cervix  and  the  ciliated  epithelia.  Numerous  specimens  must  be 
negative  for  the  gonococcus  and  positive  for  other  organisms  before 
the  disease  is  called  nongonococcal,  and  in  severe  cases  the  gonococcal 
complement  fixation  test  if  positive  is  of  great  value.  The  treatment 
of  the  endometritis  itself  is  not  of  much  diagnostic  meaning  but  that 
of  the  associated  gonococcal  lesions  is  contributive  of  proof. 

Diagnosis  of  gonococcal  chronic  endometritis  in  exact  sense  is  difficult. 
It  must  recognize  focal  inflammation  in  contrast  with  cervical  involve- 
ment and  with  cervicitis  and  endometritis  together.  The  subjective 
symptoms  are  of  little  weight  beyond  suggestions,  as  they  are  alike  in 
cardinal  characters  in  all  forms  of  endometritis.  Objective  invasion 
of  the  uterine  cavity  with  catheters  or  other  instruments  for  diagnosis 
is  no  longer  practised,  so  that  one  is  compelled  to  rely  on  extensions  of 
the  infection  into  the  tubes,  ovaries  and  peritoneum  as  important 
proofs,  because  they  are  such  common  associates.  Treatment  alone  is 
final  because  operative  and  revealing  the  exact  pathological  process 
within  the  pelvis. 

Differential  Diagnosis. — The  differential  diagnosis  chiefly  concerns 
acute  endometritis,  tubal  extension  and  degenerating  fibroids. 

Tubal  extension  differs  from  gonococcal  acute  endometritis  in  always 
having  a  history  of  severe  onset,  rapid  progress  from  the  external  geni- 
tals to  the  uterus  and  from  the  uterus  to  the  tubes  and  pelvic  cavity. 
The  subjective  symptoms  are  ovarian  pain  associated  with  intense 
systemic  symptoms  of  infection  and  absorption  and  a  distinct  tendency 
to  bowel  and  bladder  disturbance.  The  objective  lesions  must  be  deter- 
mined by  the  most  gentle  possible  examination,  because  violent  manip- 
ulation in  this  acute  disease  may  convert  a  congestion  into  a  suppura- 
tion of  the  tube  or  extend  early  tubal  lesion  to  the  ovary  and  the  peri- 
toneum. The  observer  must  be  satisfied  with  a  sense  of  fullness  and 
tenderness  in  the  tuboovarian  region,  the  fornices  of  the  vagina  and 
loss  of  mobility  of  the  cervix.  Rectal  exammation  will  often  demon- 
36 


562  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

strate  Avliat  the  vajjinal  touch  fails  to  do.  ^Manifestly  specimens  from 
the  tube  cannot  be  obtained  for  the  laboratory  except  at  operation, 
which  is  no  longer  contemplated  in  acute  stages.  Treatment  is 
of  value  in  that,  as  acute  s^Tnptoms  subside  and  chronic  signs  super- 
vene, a  fuller  physical  examination  is  possible  and  the  invaded  tube 
may  be  exactly'  outlined.  At  operation  the  condition  is  e^■ident  and 
tlie  bacteriologic  study  of  the  tubal  contents  may  be  carried  out. 

Degenerating  inmor  differs  from  gonococcal  acute  endometritis  in  having 
a  history  which  is  never  acute,  denies  infectious  intercourse  and  gono- 
coccal conditions  elsewhere  in  the  urinogenital  tract.  The  subjective 
s\Tn])toms  are  those  of  indefinite  sensations.  Bleeding  is  the  most 
prominent  sign,  which  may  be  early  but  is  usually  late.  Tlius  menstrua- 
tion is  made  excessive  and  often  metrorrhagia  appears  late.  With 
ulceration  during  the  degeneration,  shreds  of  tissue  may  be  cast  and 
should  always  be  submitted  to  the  laboratory.  The  objective  signs 
are  those  of  irregular  enlargement  of  the  womb  with  softening  but  with 
little  tenderness  unless  ulceration  is  present.  Subperitoneal,  cer\ical 
and  mural  nodules  may  be  present  and  contribute  much  to  the  diagnosis 
which  is  settled  by  the  treatment  at  operation. 

Treatment. — Variations  must  be  adopted  to  the  acute  stage,  in  which 
the  expectant  method  predominates,  and  to  the  chronic  stage  in  which 
numerous  details  are  available  according  to  conditions. 

The  prophylaxis  is  personal  and  social.  The  personal  protection 
through  great  cleanliness  of  the  hands  and  dressings  concerns  the 
eyes  and  the  vagina,  vulva  and  urethra  below  and  the  tubes  above  the 
lesion,  through  the  utmost  absence  of  excitants,  either  physical,  physio- 
logical or  therapeutic.  The  social  prevention  burns  the  dressings, 
requires  special  utensils,  toilet  articles,  bedding  and  the  like  and 
forbids  intercourse,  x^bortive  measures  are  unknown,  because  the 
endometrimn  is  inaccessible  to  any  such  attempt. 

The  essentials  of  management  are  described  in  Chapter  IX  on  General 
Principles  of  Treatment  on  page  483. 

Curative  Treatment. — All  effort  is  chiefly  expectant  and  comprises 
gentle  measures,  guiding  and  aiding  Nature's  processes  rather  than 
institutmg  great  reactions  of  their  own.  Thus  the  tendency  to  increase 
and  extension  of  the  lesion  are  avoided.  The  associated  lesions,  almost 
always  antecedent,  in  the  urethra,  vulva,  vagina  and  cervix  have 
attention  at  the  same  time. 

The  physical  measures  are  only  hydrotherapy  for  thermal  and 
cleansing  effects.  Its  local  administration  is  either  cold  or  heat  accord- 
ing to  the  comfort  of  the  patient  and  secured  by  the  ice-bag  or  coil  or 
the  hot-water  bag  or  coil  over  the  lower  abdomen.  Alcohol  sponge- 
baths  soothe  the  patient  and  limit  the  distress  of  fever.  The  douches 
must  have  the  same  preliminary  details  as  those  laid  down  for  vulvitis 
and  vaginitis  and  they  fulfill  the  same  indications  in  cleanliness,  anti- 
sepsis and  decongestion.  The  sitting  posture  on  a  douche-pan  is  best, 
to  avoid  as  far  as  possible  penetration  by  the  current  or  gravitation 
of  retained  fluid  into  the  uterus.    The  pressure  should  be  moderate 


GONOCOCCAL  ENDOMETRITIS  563 

and  the  nozzle  should  provide  well  for  the  return  flow.  No  nozzle  is 
better  than  the  double-shank  glass  type  with  a  long  and  wide  space 
between  the  two  shanks  through  which  the  outflow  occurs. 

The  posture  for  drainage  is  important  and  may  be  sitting,  lateral, 
dorsal  or  ventral.  Fowler's  position,  incomplete  or  practical  in  degree 
according  to  need  and  comfort  of  the  patient,  is  available  for  retro- 
positions,  likewise  either  of  the  lateral  positions.  The  dorsal  or  the 
ventral  positions  may  be  alternated  for  anteropositions.  Observa- 
tion of  results  will  alone  determine  and  the  patient's  comfort  must  not 
be  broken  because  such  irritation  may  augment  the  disease. 

In  its  systemic  application  hydrotherapy  offers  sitting  baths  to 
relieve  congestion  and  stasis  and  body  baths  to  soothe  and  cleanse. 

The  medicinal  measures  are  systemic  and  local.  The  former  are  not 
largely  demanded  or  serviceable,  except  anodynes  for  severe  pain, 
circulatory  sedatives  for  undue  congestion,  supportives  for  prostration 
and  tonics  for  depreciation  in  the  long  cases.  The  local  means  are  in 
the  acute  period  only  the  vulvar  and  vaginal  douches^,  at  first  cleansing, 
then  antiseptic,  as  the  case  improves. 

The  surgical  procedures  are  omitted  in  the  acute  period  in  all  cases 
but  become  important  in  many  forms  of  gonococcal  chronic  endome- 
tritis. Acute  endometritis  often  becomes  chronic  like  other  gono- 
coccal infections. 

Gonococcal  Chronic  Endometritis. — As  in  the  acute  lesion  the  manage- 
ment is  moderated  according  to  circumstances. 

The  physical  measures  are  massage  and  hydrotherapy.  Massage 
is  only  for  the  boggy  uterus  late  in  the  catarrhal  stage  without  infec- 
tion. As  in  the  prostate  its  benefits  may  be  great  and  should  be  tried. 
Local  hydrotherapy  offers  hot,  long  douches  which  benefit  the  conges- 
tion and  relaxation  of  the  organ  but  do  not  reach  the  mfected  mucosa. 
All  their  details  are  fully  discussed  under  vaginitis,  page  544.  General 
hydrotherapy  comprises  the  sitting  baths  and  the  body  baths  which 
when  properly  given  are  soothing  and  decongesting  and  fulfill  their 
other  usual  indication.    Their  influence  on  the  infection  is  indirect. 

The  medicinal  measures  are  given  systemically  and  locally.  By 
systemic  administration  the  system  is  supported  against  anemia, 
debility  and  absorption  by  the  usual  selection  of  hematinics,  stimulants 
and  eliminants.  Ergot  may  be  given  with  or  without  either  hydrastis 
or  viburnum  prunifolium  or  both,  for  a  relaxed  uterus,  such  as  would 
be  benefited  by  massage.  Serumtherapy,  as  in  cervicitis,  may  be  tried 
but  is  of  little  value.  The  more  chronic  the  stage  the  greater  the  value 
of  bacterin.  A  severe  negative  phase  should  never  be  •  provoked. 
Serimi  is  suggested  for  the  acute  period.  All  details  are  described  under 
the  general  subject  of  serumtherapy  on  page  512. 

In  the  local  adminstration  the  medicated  douches  described  in 
vulvitis  and  vaginitis  are  available.  Direct  uterine  applications  are 
of  great  value  but  must  be  used  with  utmost  aseptic,  physical  and 
chemical  caution.  The  greatest  danger  is  in  office  treatment  when 
cervical  drainage  is  not  efficient.    Applications  are  best  during  the  few 


564  aOXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

weeks  after  a  curettenient  while  the  eer\'ix  remains  wi(ie  open  for 
drainage.  Some  authorities  prefer  to  omit  them,  Tliey  had  best  not 
be  tried  without  instruetion  or  experience.  As  prehminaries  examina- 
tion must  exclude  infection  of  the  tubes,  ovaries  and  peritoneum. 
The  vulva  and  vagina  are  carefully  douched  with  the  solvents  and 
destroyers  of  ]ius  and  then  with  gentle  methods  under  strict  antiseptic 
precautions  the  slug  of  nuicus  is  removed  as  in  cer\i{'itis  and  then  the 
endometrium  is  swabbed  in  the  method  described  for  chronic  endo- 
cervicitis  on  ])age  553.  The  entire  lining  should  be  gently  but  thor- 
oughly reached  with  special  reference  to  junctm'cs  of  the  anterior  and 
posterior  walls  to  form  the  roof  and  two  lateral  walls.  The  cervix 
must  pro\ide  free  outlet  for  excess  of  fluid. 

So-called  coimterinoculation,  following  the  same  method  in  the 
vagina  and  cervix,  has  been  attempted  by  Brindeau'  with  the  bacillus 
of  lactic  acid.  Foul  exudate  is  said  to  have  been  ])rom])tly  overcome 
in  14  endometrites  and  in  78  women  with  other  gynecologic  conditions. 

The  siu'gical  measures  are  nonoperati\'e  and  operative.  Among  the 
former  class  is  chiefly  dilatation  of  the  cervix  for  drainage  and  indi- 
rectly the  applications  and  instillations.  The  operative  measures  are 
curettement  without  or  with  trachelectomy.  The  full  details  of  these 
operations  are  left  to  works  on  gynecology  but  the  following  general 
features  of  ciu'cttement  should  be  remembered.  The  case  should  be 
one  of  indolent  irresponsive  symptoms  and  defective  drainage  and  the 
time  of  election  for  the  operation  is  just  before  the  monthly  period 
when  the  soft  hypertrophy  of  the  mucosa  renders  its  removal  easily 
more  thorough.  There  should  be  no  tubal  or  ovarian  disease.  The 
instrimients  and  supplies  are  a  speculum,  tenacukmi,  uterine  probe, 
cervical  dilators,  assorted,  sharp  and  blunt  curettes  of  either  irrigating 
or  nonirrigating  type,  irrigator  and  intrauterine  douche  nozzle,  dressing 
forceps,  gauze,  swabs,  antiseptic  solution  such  as  iodin,  vulvar  pad 
and  T-binder.  The  preparation  of  the  patient  should  be  that  accepted 
in  all  hospitals  as  to  catharsis  and  the  like.  The  vulva  should  be 
shaved  and  a  very  careful  scrubbing  and  douching  of  the  vagina  given. 
The  anesthesia  is  general  and  the  position  lithotomy.  The  landmark 
is  the  cavity  of  the  uterus  whose  form,  direction  and  depth  are  deter- 
mined by  the  uterine  probe,  after  the  speculum  is  inserted  and  the 
tenaculum  attached  to  the  cervix.  The  probe  should  touch  nothing 
before  it  is  in  the  cavity  of  the  cervix.  The  curettes  shoidd  all  be  bent 
to  conform  with  the  shape  of  the  probe.  Dilatation  of  the  cervix 
precedes  the  probing  and  is  done  with  the  Hanks  or  Goodell  instrument. 
The  scraping  is  then  begun  of  both  cervix  and  body  and  irrigation  had 
best  be  omitted  unless  the  cervix  is  wide  open,  the  return  free,  the 
pressure  low  and  the  operator  experienced.  Step  by  step  from  a  fixed 
starting-point  the  posterior  surface,  lateral  edges,  tubal  outlets,  roof 
and  anterior  surface  are  all  gently  but  deeply  curetted  with  strokes 
which  travel  from  the  highest  point  to  the  os  interniun  and  which 

'  Arch.  mens,  d'obst.  et  de  gyn.,  March,  1912. 


reach  the  muscuhtr  coat,  recognized  through  the  resistant  feel  and 
rather  harsh  sound.  The  blunt  curette  or  the  irrigation  removes  the 
debris  and  the  cavity  i^  irifjjjfjfd  flfan  arjd  dry  by  sterile  gauze  wrapped 
on  the  -mallest  in-trurrjf-nt  ur  the  prrjbe  and  vigorously  drawn  over 
ah  -urfaces  from  abo^■f•  (\(>\\\\\\'dT(\.  The  lining  of  the  cervix  is  treated 
in  the  sanif  maniifT  and  th'ii  packing  for  five  or  ten  minutes  stops 
bleeding,  bjrlin  <>t  -injjlar  antise^jtic  is  then  painted  over  the  entire 
cavity-  or  a  few  mlnirns  rna,\  be  instillated  and  allowed  to  flow  out  upon 
the  vaginal  pad  pre.  iou-Iy  placed  in  the  posterior  cul-rJe-sac  to  receive 
any  specimen  and  Huh  leakage.  A  small  drain  soaked  in  iodin  may 
be  inserted  for  the  fir-t  four  to  flight  hour-.  Other  app)]ications  recom- 
mended are  nitrate  of  silver  10  per  cent.,  potassium  permanganate 
1  per  cent.,  formalin  25  to  40  per  cent.,  ichthyol  full  strength,  carbolic 
acid  and  akohol.  50  per  cent,  alcohol,  picric  acid  and  the  like.  Drains, 
if  inserted,  -hould  be  tied  to  the  \-aginal  gauze  and  both  removed  within 
a  few  hour-  or  uterine  drains  may  be  omitted  if  the  cervix  is  wide  open 
and  onl}"  the  vaginal  gauze  used,  which  in  that  case  may  remain  in  for 
one  day. 

The  aftertreatment  of  curettement  is  for  the  early  days  rest  in  bed. 
The  Fowler's  position  probably  improves  the  drainage  and  \tilvar 
lavage  should  be  practi-ed  after  each  urination  and  defecation.  ^  aginal 
douches  in  the  sitting  position  rnay  be  given  if  the  drainage  is  copious, 
with  all  the  technic  and  precaution  described  for  douches  during  endo- 
metritis. The  u.-ual  po.-toperative  diet,  drink  and  nursing  are  required. 
In  the  remote  after<:-are  the  catarrhal  stage  may  be  important  and 
requires  caution  during  the  menses.  ^Menorrhagia  may  occur  during 
the  first  few  months  and  is  controlled  by  uterine  sedatives  variou.sly 
combined,  such  as  ergot,  hydrastis  and  viburnum  pnmifolium.  Sexual 
relations  are  postponed  until  late  and  there  must  be  no  infection  in  the 
woman  or  in  the  rnan.  The  latter  condition  may  readUy  cause  a  rein- 
fection. The  dangers  of  curettement  are  a  failure  to  remove  all  the 
di.-5eased  muco.-a,  which  will  light  up  the  disease  upon  the  raw  surface, 
carry  it  into  the  myometrium  or  extend  it  into  the  annexa.  The 
cautions  are,  therefore,  thorough  removal  of  the  mucosa  with  steriliza- 
tion of  the  denuded  surface,  free  drainage  of  any  exudate  and  a  clean 
vagina  and  \"ulva  before  and  during  the  operation  and  in  the  aftercare. 

Aftertreatment. — Gonococcal  endometritis  requires  persistence  of 
treatment  for  long  jjeriods  owing  to  its  severe  character  and  slow 
progress.  Uterine  catarrh  is  a  very  common  sequel  and  may  be  almost 
impossible  to  relieve  completely.  In  the  immediate  aftertreatment 
intercourse  is  forbidden  and  the  lu-ologist  keeps  the  case  imder  observa- 
tion and  repeated  bacteriologic  test.  The  remote  aftertreatment  is 
occasional  visits  to  the  ofBce  for  these  examinations.  "Women  living 
in  legal  or  illegal  marital  relations  may  be  regarded  as  cured  if  they  do 
not  infect  the  men. 

Cure. — ^The  majority  of  cases  are  completely  relieved,  which  means 
that  the  patient  must  be  free  of  infection,  constituting  the  bacterio- 
logic cure.     A  negative  complement  fixation  test  is  also  advisable. 


566  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

The  endonietriiiin  often  recovers  so  that  cliildbearinj]:  is  ]iossible,  but 
steriHty  is  the  rule  after  jronococcal  infections  so  that  in  this  sense 
patliologic  cure  is  often  not  seen.  Synii)toniatic  cure  is  relief  of  pain 
associated  witli  or  independent  of  menses  and  relative  or  absolute 
freedom  from  discharge. 

GONOCOCCAL  METRITIS. 

Varieties. — 'I'he  usual  subdivisions  as  to  course  are  acute  and  chronic, 
complicated  and  uncomplicated.  Subacute  forms  cannot  be  distin- 
guished. As  to  occurrence  metritis  is  always  secondary  and  never 
primar\',  and  as  to  inxoh'cment  it  may  be  superficial  or  deep,  general 
or  disseminate,  respectiA-ely  in\olving  the  myometrium  or  focalized  in 
one  or  a  few  jioints. 

Gonococcal  Acute  Metritis. — Significance. — Significance  rests  chiefly 
in  its  presence  as  the  extension  of  acute  or  chronic  endometritis  and 
as  the  sign  of  severe  forms  of  infection. 

Etiology. — The  etiology  is  always  a  severe  endometritis  rapidly 
extending  along  the  mucosa  and  penetrating  beneath  it  usually  in  a 
soil  rendered  fertile  by  physiological  processes  such  as  menstruation 
and  childbirth  or  by  pathologic  incidents  such  as  miscarriage  and 
abortion.  The  gonococcus  is  the  exciting  factor  with  or  without  its 
allies  of  the  pyogenic  group,  notably  the  streptococcus,  staphylococcus 
and  the  Bacillus  coli.  The  degree  of  infection  is,  as  in  all  other  invasion, 
dependent  on  tlie  \'irulence  and  number  of  organisms  invading  and  the 
resistance  of  the  patient,  either  as  idiosyncrasy  toward  the  gonococcus 
and  pus  organisms  or  as  general  low  condition  of  health.  The  presence 
of  the  gonococcus  in  the  uterine  muscularis  was  demonstrated  by 
]\Iadlener.^ 

Pathology. — The  pathology  represents  advancement  of  the  gono- 
coccus from  the  mucosa  of  the  endometrium  into  the  muscle  layer  of 
the  wall  of  the  uterus  and  the  essence  is  the  characteristic  change 
embodied  in  h\'peremia  and  cellular  stimulation  of  the  muscle  sub- 
stance during  the  acute  form  and  in  congestion  and  cellular  substi- 
tution during  the  chronic  form.  INIacroscopicall}^  are  shown  conges- 
tion, softening,  enlargement  and  often  involvement  pf  the  uterine 
annexa  and  microscopically  are  seen  changes  similar  to  those  of  endo- 
metritis with  the  exfoliation  omitted  as  there  is  no  surface  exposed. 
These  temporary  lesions  may  fully  subside  but  the  permanent  lesions 
are  the  infiltrations  and  cellular  changes  concomitant  with  the  parallel 
conditions  in  the  endometrium.  The  associated  lesions  are  regularly 
endometritis,  salpingitis,  oophoritis  and  peritonitis,  because  an  hifec- 
tion  sufficiently  active  to  attack  the  myometrimn  has  its  origin  in  the 
endometrimn  and  almost  always  extends  promptly  to  the  tubes, 
ovaries  and  serosa. 

In  the  chronic  form  the  changes  may  be  a  submucous  penetration 

■  Cent.  f.  Gyu.,  1895,  No.  50. 


GONOCOCCAL  METRITIS  567 

of  the  disease  diffuse  or  disseminate,  or  it  may  be  a  deep  general  pene- 
tration into  the  miiseiilar  substance  in  various  sections  of  the  orj^an 
or  in  the  muscularis  as  a  whole.  In  some  instances  the  endorn(;trium 
is  found  recovered,  more  or  less  completely,  while  the  myometrium 
alone  is  diseased.  In  other  cases  both  the  endometrium  and  the 
myometrium  are  similarly  and  equally  affected  in  their  general  extent 
or  in  various  portions  only. 

Complications. — ^The  complicating  lesions  are  those  of  gonococcal 
disease  in  the  system  at  large  or  in  the  upper  urinary  tract,  as  is  the 
rule  in  all  other  intense  and  progressing  manifestations  of  this  organism. 

Symptoms. — ^The  symptoms  are  subjective  and  objective,  local  and 
systemic  and  vary  with  the  periods  of  invasion,  establishment  and 
termination.  The  character  of  the  infection  as  a  sequel  of  endome- 
tritis makes  it  almost  impossible  to  recognize  the  invasion  unless  a 
lighting  up  of  all  the  symptoms  characterizing  the  endometritis  and 
especially  of  those  in  the  system  at  large  suggests  an  extension  of  the 
process  which  is  found  not  to  be  in  the  annexa  of  the  womb.  The  sub- 
jective local  symptoms  are,  therefore,  those  of  the  antecedent  endo- 
metritis augmented  in  degree,  prolonged  in  course  and  resistant  to 
treatment.  The  invasion  is  typically  septic  when  present — chill  or 
chilliness,  anorexia  with  nausea  or  vomiting,  diarrhea  or  constipation, 
excited  pulse  and  respiration  and  a  fever  with  wider  daily  variations. 
The  establishment  possesses  sensory,  functional  and  exudative  elements. 
There  is  dragging  and  heavy  feeling  in  the  milder  cases  advancing  to 
real  pain  in  the  more  active  cases  and  the  function  always  shows 
excessive  and  otherwise  disturbed  menstruation  and  even  lactation 
may  be  decreased  or  abolished  as  in  any  other  septic  process.  The 
exudate  of  endometritis  is  at  first  decreased,  much  as  that  of  urethritis 
in  the  male  is  decreased  when  the  prostate  becomes  involved  and 
later  it  is  greatly  increased  and  altered.  Hemorrhagic  quality  may  be 
added  and  alarm  the  patient,  sometimes  as  fresh,  oftener  as  dark 
altered  blood. 

The  objective  local  symptoms  through  the  speculum  show  the  cervix 
soft,  boggy,  patulous  and  dilatable,  combining  endocervicitis  and 
myocervicitis.  The  discharge  after  the  temporary  decrease  of  the 
invasion  is  copious,  piu-ulent  and  bloody  or  at  times  mucopm-ulent 
and  seropujulent  varying  with  the  free  quantity  of  uterine  as  com- 
pared with  cervical  elements.  Like  the  cervix,  the  body  of  the  uterus 
is  soft,  distinctly  tender  and  generally  or  locally  enlarged.  The  asso- 
ciated lesions  are  easy  of  detection  and  comprise  the  antecedent  gono- 
coccal foci  in  the  external  and  lower  lu-inogenital  organs  and  of  con- 
comitant or  secondary  involvement  in  the  oviducts,  ovaries  and  pelvic 
peritoneum — each  with  its  familiar  and  tj^Dical  physical  signs. 

The  termination  in  the  mild  cases  only  is  a  slow  subsidence  of  the 
acute  symptoms  and  a  possible  recovery  but  the  tendency  and  common 
experience  as  in  all  other  gonococcal  lesions  is  for  chi'onic  metritis  to 
supervene.  As  stated  under  pathology  the  endometritis  may  prac- 
tically or  actually  recover  before  the  metritis  does,  but  the  rule  is  for 


568  GONOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

these  two  cDiulitioiis  wliieh  are  nuitually  e;uisati\e  in  their  rehitiou 
to  lia\e  the  same  course  and  termmatioii  in  a  \o\\  ^rade  of  chronic 
disease. 

Gonococcal  Chronic  Metritis.  Significance. — Significance  may  be 
regarded  as  tlie  final  degree  of  gonococcal  disease  so  far  as  the  uterus 
itself  is  concerned  and  is  therein  analogous  with  the  chronic  gonococcal 
invasions  of  the  prostate  in  the  male. 

Etiology.— ^ The  etiology  is  the  gonococcus  without  or  with  its  allies 
of  the  i)yogenie  group  which  after  Inning  caused  a  severe  and  extending 
endometritis  reaches  the  myometrium. 

Pathology. ^ — The  pathology  has  been  fully  discussed  tnider  gono- 
coccal actite  metritis  in  drawing  a  comparison  between  it  and  the 
chronic  form. 

Symptoms. — Tlie  symptoms  are  subjective  and  objective,  local  and 
systemic  and  are  peculiar  in  the  absence  of  any  invasion  unless  the 
prolongation  of  the  acute  symptoms  may  be  regarded  as  the  period. 
Ordinarily  the  lesion  may  begin  as  a  subacute  or  chronic  process  so 
that  establishment  is  the  period  at  which  the  disease  is  usually  seen. 
The  ty])e  of  symptoms  is  that  of  chronic  endometritis  liigher  in  degree, 
more  prolonged  and  more  profound  in  their  pathogenic  basis.  The 
subjecti^•e  local  symptoms  are  sensory,  functional  and  exudate.  There 
is  mtich  more  ])ain  in  the  progressing  cases  and  higher  discomfort  in  the 
stationary  and  indolent  cases.  ^lenstrual  function  is  more  profotmdly 
and  obstinately  changed  and  metrorrhagia  is  by  no  means  uncommon. 
A  persistent  characteristic  leucorrhea  is  often  the  chief  complaint. 
The  objective  local  s\inptoms  are  a  cervix,  in  spectilmn,  com])r()mised 
by  chronic  congestion  so  that  it  is  soft,  relaxed,  patulous  and  filled 
with  exudate.  The  body  is  enlarged  uniformly  and  in  all  directions 
and  there  is  much  tenderness  not  so  acute  but  more  constant  and  endur- 
ing than  in  the  acute  stage.  The  discharge  is  characteristic  exactly 
like  that  of  chronic  endometritis  with  the  element  of  hemorrhage 
rather  frequently  added. 

The  termination  is  a  questionable  factor.  The  mild  cases  may 
recover  with  little  serious  anatomic  or  physiologic  change  but  the 
average  ease  has  no  cure  in  the  full  sense  in  that  chronic  catarrh  or 
low-grade  suppuration  with  or  without  relapses  is  the  rule.  iNIenstrual 
disorder  persisting  for  the  remainder  of  the  woman's  sexual  life,  with 
sterility  or  frequent  miscarriage  and  abortion,  is  the  usual  sequel, 
typifying  the  profotmd  damage  of  the  endometriimi  and  myometrium. 

Diagnosis  of  Gonococcal  Metritis. — The  <liagnosis  of  actite  metritis 
is  a  very  imjjortant  but  a  rather  difficult  matter.  In  the  history  are 
the  factors  of  infecting  coitus  or  in  married  women  of  gonococcal 
disease  of  subacute  or  chronic  type  in  the  husband,  from  which  pro- 
ceeds the  story  of  urethral,  pudendal  and  vaginal  signs  with  the  signifi- 
cant addition  of  ra])id  extension,  early  uterine  involvement  and  per- 
haps finally  annexal  disease.  The  stibjective  symptoms  arc  the  deep- 
seated  heavy  pain,  discomfort  and  discharge  with  prompt  and  \'iolent 
menstrual  disorder,  and  the  objective  signs  are  those  of  obvious  sys- 


GONOCOCCAL  MET  HIT  I H  509 

temic  infection  with  its  prostration  and  fever.  The  cervix  and  uterus 
are  much  altered  from  the  muscular  invasion  and  often  the  annexa  arc; 
involved.  Such  extension  to  the  annexa  associated  with  profound 
uterine  changes  is  most  important  in  the  diagnosis.  The  laboratory 
readily  discovers  the  gonococcus  in  the  discharge  from  the  cervix  and 
externalia  and  later  the  positive  gonococcal  com[)lem('nt  fixation  test 
may  be  elicited.  The  blood  count  of  pus  process  is  heli>ful  if  pyog(-'rn'c 
organisms  are  present  but  may  be  less  manifest  with  the  gonococcus 
alone,  much  as  is  seen  in  prostatic  disease  of  the  male.  Success  of 
antigonococcal  treatment  in  the  urethra  and  externalia  is  a  suggestion 
of,  but  not  a  positive  proof  of,  the  nature  of  the  infection  which  may  be 
mixed  and  not  pure.  Anatomical  diagnosis  is  often  supplied  c^nly  by 
the  operation. 

Differential  Diagnosis. — Differential  diagnosis  defines  gonococcal 
acute  from  pyogenic  acute  metritis.  It  must  be  remembered  that 
these  two  forms  are  often  associated. 

Pyogenic  (streptococcic)  differs  from  gonococcal  acute  metritis  in  its 
history  of  infection  after  miscarriage,  abortion  or  childbirth  rather 
than  after  illicit  intercourse,  with  its  s}Tiiptoms  of  urinogenital  infec- 
tion. Its  onset  is  more  intense  and  its  progress  more  rapid  and  its 
penetration  deeper,  because  its  extension  is  by  the  lymphvessels  and 
lymphspaces  rather  than  the  surface  of  the  mucosa  alone  or  by  pene- 
tration after  involvment  of  the  surface.  The  gonococcus  is  typically 
superficial  in  its  habitat  and  exceptionally  deep,  in  contrast.  The 
subjective  symptoms  may  be  little  or  marked  locally;  even  in  the  most 
virulent  cases  they  may  be  insignificant.  On  the  other  hand,  extreme 
systemic  disturbance  of  advancing  sepsis  may  be  present  both  in  the 
invasion  and  establishment  and  the  objective  signs  are  the  blood  count 
of  a  pus  process  and  a  negative  gonococcal  fixation  test.  The  hm- 
phatics  of  the  broad  ligament  and  the  substance  of  the  broad  ligament 
are  invaded  while  the  tubes  and  ovaries  themselves  may  escape.  There 
are  no  gonococcal  lesions  in  the  external  parts  and  such  local  lesions 
of  the  surface  as  may  be  apparent  may  be  slight — out  of  all  proportion 
with  the  severe  systemic  reaction.  The  laboratory  detects  the  strepto- 
coccus, staphylococcus  and  colon  bacillus  but  not  the  gonococcus. 
The  complement  fixation  test  for  the  gonococcus  is  negative  and  the 
blood  count  is  positive  for  pus  formation  except  in  fulminating  cases 
having  so  much  depression  that  a  leukocytosis  does  not  develop. 
The  treatment  along  antigonococcal  lines  is  of  no  avail  and  often  the 
exact  anatomical  diagnosis  cannot  be  reached  without  operation. 

Treatment  of  Gonococcal  Metritis. — ^The  plan  is  limited  by  the  acute 
or  chronic  stage  and  by  complicated  and  uncomplicated  lesions.  The 
complications  are  the  extensions  to  the  appendages  and  peritoneum. 
Each  is  dealt  w^ith  under  its  own  heading. 

The  prophylaxis  is  the  proper  care,  as  already  stated,  of  each  lesion 
lower  in  the  sexual  system  with  special  reference  to  endometritis  and 
endocervicitis.  Too  violent  and  frequent  treatment  of  these  may  be 
the  source  of  the  metritis.     Care  in  everv  examination  so  as  not  to 


570       GONOCOCCAL  INFECTION  IN  THE  FEMALE 

traumatize  the  uterus  is  essential.  Good  nianagenieut  and  careful 
treatment  may  do  much  to  prevent  an  endometritis  from  involving 
the  muscularis.    Abortive  measures  do  not  apply. 

(nniococcdl  Acute  Mrtritis. — In  the  acute  metritis,  all  the  elements 
of  management  discussed  in  endometritis  apply  in  hygiene,  rest, 
exercise,  diet,  drink  and  nursing.  The  severity  of  the  muscular 
invasion  renders  contuuiation  of  these  measures  rather  longer  than  hi 
endometritis. 

The  ])li\'sical  measures  are  also  the  same  as  in  gonococcal  infection 
of  the  lining  of  cervix  and  uterus.  The  vaginal  douches  are  of  value 
only  for  their  heat  eii'ect  on  the  uterus,  and  for  soothing  and  cleansing 
the  vagina  and  vulva.  They  cannot  possibly  reach  the  muscularis 
directly. 

The  ice-bag  or  ice  coil  or  the  hot-water  bag  or  coil,  during  the  early 
painful  period  is  of  great  value.  Sitting  and  body  baths  as  soon  as 
the  patient  may  be  moved  for  them  complete  the  hydrotherapy.  ]\Ias- 
sage  may  be  employed  only  during  the  late  chronic  period  for  relaxa- 
tion of  the  muscle  but  is  forbidden  if  abscess  is  suspected.  Posture 
must  promote  drainage  of  the  pus  into  the  vagina  and  from  the  vagina 
into  a  dressing.     Its  details  are  given  under  endometritis. 

The  medicinal  measiu-es  are  systemic  and  local.  By  systemic  admin- 
istration the  infection  is  little  influenced  directly  but  catharsis,  diuresis 
and  diaphoresis  are  all  of  elmiinating  value.  The  relaxed  and  indolent 
muscle  may  be  stimulated  and  toned  by  ergot  and  hydrastis.  Pain 
and  extension  are  controlled  by  opiates  and  belladonna.  Seruni- 
therapy  is  as  yet  none  too  exact.  The  serum  may  be  of  advantage  in 
the  acute  period  and  the  bacterin  in  the  chronic  stage.  The  local 
measures  are  the  hot  solvent  and  antiseptic  douches.  As  stated  under 
hydrotherapy,  its  influence  is  only  mdirect  but  is  sufficiently  great  to 
make  it  worth  while.  When  the  metritis  is  at  an  end  the  persisting 
endometritis  deserves  the  local  measures  already  described. 

The  surgical  treatment  is  variously  regarded.  The  majority  of 
authors  teach  that  when  in  doubt  nothing  radical  should  be  done  and 
only  expectant  means  employed.  Findley^  says:  "The  curette  has  no 
place  in  the  treatment  of  acute  metritis."  There  are  the  two  dangers 
of  the  infection  itself  and  of  the  operation  itself.  Safety  indicates 
leaving  the  majority  of  these  patients  surgically  alone.  Dudley,^ 
on  the  other  hand,  considers  the  cases  as  they  show  sapremia,  bac- 
teremia and  septicemia  or  pyemia.  Sapremia  cases  may  be  cleansed 
of  the  detritus  with  the  finger  as  a  ciu"ette  and  mopped  clean  with 
gauze.  This  operation  is  relatively  safe.  The  bacteremic  and  septi- 
cemic cases  had  best  be  left  alone  especially  if  Nature  is  doing  well. 
If  Nature  is  not  doing  well  and  if  possible  benefit  may  come  by  cleaning 
the  uterus,  then  according  to  observation  by  several  authors  including 
Pryor*  and  Krug,''  rapid  curetting  with  thorough  sterilization  of  the 

»  Loc.  cit.,  p.  439.  2  Loc.  cit.,  p.  216. 

3  New  York  Jour.  Gynec.  and  Obst.,  1892,  ii,  86;  Am.  Jour.  Obst.,  1892,  xxv,  p.  598. 
*  Am.  Jour.  Obst..  1892,  xxv,  822. 


GONOCOCCAL  METRITIS  571 

denuded  surface  with  iodin  or  similar  applications  may  remove  the 
chief  focus  of  absorption.  As  applied  to  gonococcal  infection,  any  of 
the  foregoing  conditions  involves  mixed  infections  of  which  the  bacteri- 
ology must  be  known. 

Gonococcal  Chronic  Metritis. — ^All  the  principles  of  prophylaxis 
noted  for  the  acute  stage  are  used,  being  continued  from  the  latter 
and  there  are  no  abortive  measures.  Chronic  endometritis  indicates 
the  management  of  chronic  metritis  in  the  hygiene,  rest  before,  during 
and  after  menses  and  during  menorrhagia.  Exercise  is  regulated  for 
maintaining  the  acme  of  health  and  avoiding  deep  congestion.  All  the 
mild  sports  may  be  taken  up  progressing  from  walking  and  all  the 
severe  sports  are  avoided.  Diet,  drink  and  nursing  are  matters  of 
familiar  knowledge  and  have  already  been  noted  under  chronic  endo- 
metritis. 

The  physical  measures  are  chiefly  thermal  in  the  form  of  hydro- 
therapy and  heliotherapy.  During  the  pain  of  menstruation  the  hot- 
water  bag  or  coil  or  in  rare  cases  the  ice-water  bag  is  of  service.  The 
douches  are  only  indirect  decongestants,  likewise  the  sitting  and  body 
baths. 

The  heliotherapy  is  important  and  is  applied  over  the  pelvis  encased 
in  a  sheet-iron  box  containing  numerous  electric-light  bulbs  and  a 
thermometer.  With  an  ice-cap  or  cold  towel  on  the  head,  the  tempera- 
ture of  the  cabinet  is  raised  to  tolerance  and  without  prostration  or 
headache.  The  application  is  continued  for  from  ten  to  thirty  minutes 
and  repeated  every  other  day  or  so,  according  to  result.  The  powerful 
hyperemic  and  actinic  effects  of  the  light  and  heat  promptly  remove 
the  pain  and  dragging,  absorb  the  exudate  and  decrease  the  discharge 
and  other  symptoms. 

The  medicinal  measures  are  systemic  and  local.  Except  for  support 
of  the  system  in  removing  anemia  and  other  signs  of  absorption, 
systemic  administration  is  of  little  value.  Local  treatment  is  by 
douches  and  applications.  Douches  decongest  indirectly  by  the  action 
of  heat  and  must,  therefore,  be  hot,  long  and  regularly  given  with  rest 
in  bed  after  them,  as  already  noted  under  vaginitis.  Their  service  in 
removing  pus  from  the  vagina  and  vulva  is  important.  Applications 
are  of  service  only  in  benefiting  the  antecedent  endometritis.  Their 
choice  and  technic  are  described  under  this  subject  on  page  544. 
Findley^  claims:  "Formalin  in  full  strength  is  an  excellent  antiseptic 
application.  It  penetrates  deeply  but  is  not  known  to  cause  stenosis. 
Formalin  is  applied  by  means  of  a  swab."  Injections  are  dangerous 
through  possible  penetration  of  the  tubes  and  peritoneiun,  but  instilla- 
tions of  a  few  drops  of  mild  antiseptic  may  be  tried  if  the  return  flow  is 
not  impeded.  Drainage  of  the  uterus  must  be  good  m  all  these  treat- 
ments, as  already  shown. 

Aftertreatment  of  Nonoperative  Metritis. — All  the  principles  of  both 
immediate  and  remote  aftercare  are  the  same  as  in  endometritis.    The 

iLoc.  cit.,  p.  439. 


572  GONOCOCCAL  IXFECTIOX  I\  THE  FEMALE 

most   important  element  is  personal  and  soeial  pr(>j)hylaxis  in  the 
certaint>'  of  removal  of  the  infeeting  orsjanism. 

Cure. — The  severity  of  a  gonoeoeeal  disease  whieh  passes  steadily 
upward  into  the  myometrium  neeessarily  leaves  damage  behind  it  so 
that  pathological  cure  is  probably  very  rarely  secured.  This  is  par- 
ticidarly  true  concern inf;  the  major  operations  which  remove  the  foci 
antl  seciuels  of  the  disease  but  mutilate  the  ])atient  by  (lei)rivinfi;  her 
of  part  of  or  all  her  oriijans.  Syuii)t()matic  cure  may  thus  be  reached, 
but  its  ideal  is  functional  restoration,  as  in  endometritis,  without 
relapses,  dysmenorrhea,  sterility,  extensions  into  the  tubes  and  ovaries 
and  a  chronic  leucorrhea.  Bacteriologic  relief  im})lies  absence  of  infec- 
tion which  rests  ])ractically  on  the  orijanisms  in  the  endometrium  and 
hematology  should  show  a  negative  complement  fixation  test. 

Surgical  Treatment. — The  surgical  treatment  is  nonoperative  and 
operative.  Oilatation,  drainage  and  applications  are  the  chief  non- 
operative  means,  as  elucidated  under  endometritis  on  page  5G2.  Bier's 
method  is  said  to  be  of  value.  A  special  cervical  cup  embraces  the 
cervix  through  the  vagina  and  the  vacuum  is  made  with  peculiar 
syringe  evacuating  as  the  piston  is  pressed  in.  This  is  the  method  of 
Jayle  and  Loewy,^  who  apply  the  treatment  daily  for  five-minute 
sittings  in  a  total  determined  by  the  result. 

The  damaged  uteri  left  behind  by  gonococcal  metrites  associated 
with  other  pus-processes  are  manifestly  those  which  require  major 
operations.  Gonococcal  metritis  without  complication  in  the  append- 
ages does  not  often  lead  to  them,  according  to  the  majority  of 
authorities. 

The  operative  technics  are  curetting,  amputation  of  the  cervix  and 
hysterectomy  with  or  without  the  removal  of  the  appendages. 

Curetting. — This  operation  has  been  detailed  as  to  technic  under  endo- 
metritis on  page  565.  It  is  selected  for  cases  of  menorrhagia  rather 
than  leucorrhea.  The  cavity  should  be  painted  with  iodin  or  other 
mild  stimulant  and  antiseptic  at  the  operation  and  one  or  more  times 
during  the  convalescence  according  to  indications,  and  only  in  the 
presence  of  free  drainage. 

Amputation  of  the  Cervix. — This  form  of  treatment  is  reserved,  in  the 
selection  of  case,  for  some  chronic  cases  in  which  the  cervical  and 
uterine  mucosa  are  diseased  and  refuse  response  to  treatment  but  in 
which  the  appeiiflages  are  normal.  Intractable  endocervicitis  with 
endometritis  especially  in  the  presence  of  lacerations  sums  up  the 
indications.  The  instruments  and  supplies  are  a  weighted  speculum, 
vaginal  retractors,  uterine  probe,  vulsellum,  scissors,  scalpel,  needle- 
holder,  needles,  ten-day  chromic  catgut,  silkworm  gut,  dressings  and 
T-binder.  The  preparation  of  field  and  patient  is  that  accepted  in  any 
first-class  hospital,  including  full  shaving  of  the  pudendum  and  vulva 
and  toilet  of  the  vagina.  The  anesthetic  is  general  by  choice  and  any 
ether-sequence  is  preferred  in  the  absence  of  contraindications.    The 

>  Presse  m6d.,  Paris,  1907,  xv,  81.3. 


GONOCOCCAL  METR/riS  573 

posture  is  lithotomy  and  the  landmarks  are  the  uterus  whose  depth, 
form  and  position  must  be  measured  by  the  uterine  probe  and  the 
length  of  the  cervix  determined.  The  anterior  lip  of  the  cervix  is 
seized  with  the  vulsellum  and  a  preliminary  curettage  with  liberal 
application  of  iodin  is  done  in  this  operation  as  in  all  others  upon 
the  uterus  in  the  presence  of  any  infection  and  especially  gonococcal 
infection.  The  posterior  lip  of  the  cervix  is  then  seized  with  the  forceps 
and  the  uterus  drawn  down  as  far  as  possible. 

The  incision  in  the  Schroeder  operation  is  a  bilateral  median  bifurca- 
tion of  the  cervix  to  the  depth  of  the  tear  or  obvious  disease,  thus 
creating  an  anterior  and  posterior  lip.  Sharp-pointed  heavy  scissors  are 
best  for  this  incision.  The  amputation  consists  in  removing  each  lip 
from  its  free  margin  to  near  the  base  in  a  wedge  whose  base  is  distal 
and  whose  apex  is  proximal.  With  the  scalpel  each  lip  is  evenly  incised 
from  side  to  side  obliquely,  passing  away  from  the  endocervical  mucosa 
for  the  inner  flap  and  away  from  the  vaginal  mucosa  for  the  outer  flap 
of  first  the  posterior  and  then  in  turn  of  the  anterior  lip.  Thus  are  left 
an  inner  and  an  outer  flap  in  each  lip  as  originally  made.  The  two 
inner  flaps  are  lined  with  the  endocervical  mucosa  for  most  of  their 
surface  and  the  two  outer  flaps  are  covered  with  the  vaginal  mucosa. 
The  raw  surfaces  of  the  flaps  must  be  opposed  in  order  to  create  a  new 
cervical  canal,  external  os  and  vaginal  portion  of  the  cervix.  The 
sutures  are  placed  for  even  apposition,  without  tension,  constriction  or 
gaps,  leaving  the  mucous  surfaces  intact  and  the  vaginal  surfaces 
complete  and  the  canal  patent.  Ten-day  chromic  gut  is  preferred  for 
these  sutures  but  silkworm  gut  may  be  used.  The  dressing  consists  in  a 
very  small  uterine  drain,  which  may  be  omitted,  and  vaginal  gauze, 
a  vulvar  pad  and  a  T-binder. 

Aftertreatment. — ^The  drain  and  packing  are  removed  in  twenty-four 
hours.  Douches  are  not  employed  except  for  special  mdications.  The 
conditions  of  the  sutures  must  be  known  on  about  the  fifth  day  and 
their  removal  is  on  the  tenth  or  later  day.  These  details  are  the 
immediate  aftertreatment  combined  with  the  usual  attention  to  the 
bowels,  urine  and  bodily  comfort  of  the  patient  by  good  nursing. 
Remote  aftercare  is  attention  to  the  gonococcal  infection  as  still 
possibly  persisting. 

Chire. — In  the  pathological  sense  the  cure  is  removal  of  the  chief 
germ -bearing  area.  The  new  cervix  should  have  good  form  and  free 
canal  and  in  the  symptomatic  sense  leucorrhea  and  menorrhagia  should 
be  relieved.  Bacteriologically  in  the  final  outcome  the  gonococci  are 
absent. 

Hysterectomy. — The  following  varieties  are  available:  As  to  route 
vaginal  and  abdommal,  of  which  the  former  is  inadvisable  in  gono- 
coccal lesions  of  the  appendages  because,  unlike  the  latter,  the  work 
cannot  be  done  under  the  eye;  and  as  to  degree  the  total  and  subtotal 
operations  are  recognized.  In  the  former  the  whole  womb  with  or 
without  both  appendages  is  removed  and  in  the  latter  a  wedge-shaped 
segment  of  the  body  is  taken  without  or  with  the  appendages  in  part  or 


574  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

whole  according  to  indications.  Kelly^  in  1909  seems  to  have  originated 
this  technic  and  was  followed  by  Beiittner-  in  1911,  Norris  in  his 
classic  work,  (lonorrhea  in  Women,  ascribes  it  to  Kelly  while  Findley^ 
credits  it  to  Beuttner.  In  total  hysterectomy,  therefore,  the  entire 
internal  sexual  organs  including  the  cervix  are  ablated,  while  in  sub- 
total hysterectomy  tliat  part  of  the  corpus  remains  just  above  the 
cer\-ix,  with  one  or  both  tubes  and  always  with  one  or  both  ovaries. 
One  o\ary  must  remain  with  considerable  endometrium  so  that  ovula- 
tion and  menstruation  will  both  be  possible. 

In  the  selection  of  case  gonococcal  endometritis  and  metritis  must  be 
obvious,  the  lesions  profound,  the  annexa  extensively  involved  and  no 
results  jiossible  with  other  treatment,  for  determination  of  total 
hysterectomy.  The  other  or  subtotal  hysterectomy  is  indicated  in 
young  women  for  whom  o\-ulation  and  menstruation  are  very  imi)()rtant. 
The  womb  is  less  diseased  and  at  least  one  ovary  practically  normal  and 
one  or  lioth  tubes  the  chief  site  of  complication  so  that  the  fundus  of  the 
corpus  uteri  with  the  tubal  implantation  and  the  all'ected  o\'ary  are 
ablated.  Damaged  uteri  left  by  gonococcal  metrites  with  or  without 
other  pus  processes  are  manifestly  those  requiring  either  of  these  major 
operations. 

The  ])reliminary  curetting  is  in  order  with  free  use  of  iodin  and  with 
packing  of  the  uterus  and  suture  of  the  cervix  according  to  the  form 
of  hysterectomy  chosen. 

Total  Hysterectomy. —  Among  the  instruments  and  supplies  are 
scalpels,  scissors,  hemostats,  long  forceps,  skin  and  parietal  retractors, 
broad  ligament  clamps,  sponge-holders,  ligature  carriers,  ligatures 
and  sutures,  peritoneal  and  skin  needles,  needle-holders,  dressings, 
adhesive  plaster  and  binder.  In  the  preparation  t)f  field  and  patient 
iodin  is  applied  to  the  skin  after  shaving  the  abdomen  and  vulva  and 
the  vagina  must  receiA'e  a  special  toilet  and  may  be  left  lightly  filled 
with  iodoform  gauze.  The  anesthetic  is  always  general  with  one  of  the 
usual  ether  sequences.  The  posture  is  at  first  dorsal  followed  by  partial 
or  full  Trendelenburg  position.  The  superficial  landmarks  are  the 
symphysis  pubis  below  and  the  umbilicus  above.  The  deep  landmarks 
are  the  uterus  itself,  with  the  broad  ligaments  bilaterally,  the  l)ladder 
in  front  and  the  rectmn  behind.  The  incision  is  vertical  a  little  to  either 
side  of  the  umbilical  marghi  or  transverse  after  Pfannenstiel's  methods, 
passing  through  the  superficial  field  of  the  cutaneous,  fascial,  apon- 
neurotic,  muscular  and  peritoneal  layers,  exposing  the  deep  field  com- 
prising the  pelvic  cavity  and  its  contents  after  walling  back  the  intes- 
tines in  all  directions.  The  uterus  is  recognized  first  and  then  adhesions 
before  and  behind  are  broken  down.    The  broad  ligaments  are  traced 

1  Tr.  Am.  Gynec.  Soc,  1909,  xxxiv,  536. 

2  Die  transversale  fundale  Keilexcision  des  Uterus  nebst  einigen  Bomorkungen  zur 
kon.servativen  Chirurgie  dor  Adnexe,  Stuttgart,  1911;  also  Tr.  Internat.  Cong.  Med., 
London,  1913  (1914),  See.  VIII,  Ob.st.  and  Gynec,  ii,  131. 

'  Loc.  cit.,  p.  441,  giving  the  name  wrongly  as  Bruettner. 


GONOCOCCAL  METRITIS  575 

bilaterally  and  their  adhesions  entirely  freed,  leaving  the  uterus  and  its 
diseased  annexa  under  control.  If  both  tubes  and  ovaries  are  to  be 
sacrificed,  the  ovarian  arteries  are  doubly  tied  at  the  pelvic  brim,  just 
beyond  the  infundibulum.  Less  advisable  than  two  ligatures  are  two 
clamps  which  subsequent  tying  of  the  vessels  proximal  to  the  clamps. 
The  division  of  the  broad  ligaments  is  carried  toward  the  uterus  between 
the  ligatures  or  clamps  tying  vessels  as  encountered  up  to  the  round 
ligaments  which  are  doubly  ligated  and  divided.  The  opposite  broad 
ligament  is  next  managed  in  exactly  the  same  method.  Usually 
at  this  point  with  the  scalpel  the  peritoneum  on  the  anterior  surface  of 
the  womb  is  divided  down  to  the  muscularis  from  round  ligament  to 
round  ligament  and  the  peritoneum  of  the  posterior  surface  is  likewise 
cut  through.  With  blunt  dissection  both  peritoneal  flaps  are  dissected 
free  of  the  uterus  as  far  as  the  vagina  in  front  and  the  rectum  and 
vagina  behind,  thus  freeing  the  bladder  and  the  bowel  from  the  field  of 
work.  The  uterine  arteries  are  sought  in  the  bases  of  these  fiaps  and 
doubly  ligated  close  to  the  cervix,  thus  sparing  the  ureter,  which  lies 
laterally  beyond  the  point  of  passing  the  carriers.  The  vaginal,  cervical 
and  uterine  stems  of  the  ^rtery  must  be  collectively  or  separately 
secured.  The  artery  may  be  dissected  from  its  bed  beyond  and  behind 
the  ureter  and  tied  at  the  main  trunk,  if  desired.  The  uterus  and  both 
appendages  are  now  free  in  the  pelvis  except  for  the  vaginal  implan- 
tation. This  passage  is  opened  below  the  cervix  after  gauze  protection 
of  the  pelvic  field  and  the  wall  divided  completely  on  the  finger  to  guard 
the  bladder  and  the  rectum.  Spurting  vessels  are  individually  secured 
and  after  removal  of  the  loose  packing  in  the  vagina  from  below  by  the 
nurse,  the  walls  are  sutured  completely  to  bring  raw  surfaces  and  not 
mucosa  together.  The  peritoneal  edges  of  the  stumps  of  the  broad 
ligaments  and  the  anterior  and  posterior  peritoneal  flaps  are  sutured 
directly  across  the  pelvic  floor  from  side  to  side,  leaving  no  raw  points 
and  infolding  to  fill  small  cavities.  The  toilet  of  the  peritoneum  is 
thorough  to  remove  free  blood,  clots  or  exudate.  No  drains  are  used 
and  a  layer  suture  closes  the  abdomen.  A  careful  dressing  with  liberal 
firm  strapping  covered  in  with  pads  and  binder  finishes  the  operation. 
A  piece  of  gauze  may  be  lightly  placed  in  the  vagina  and  left  for  twelve 
to  twenty-four  hours. 

If  the  ovary  and  tube  are  to  remain  on  one  or  both  sides  all  the  steps 
are  the  same  except  that  the  incision  through  the  broad  ligament 
begins  at  the  cbrnu  uteri  and  passes  vertically  along  each  side  of  the 
corpus  through  the  tube  and  round  ligament.  The  anterior  and 
posterior  flaps  of  peritoneimi  are  then  made  and  the  remainder  of  the 
operation  is  as  previously  described.  These  steps  may  all  be  taken 
between  double  ligatures  or  double  clamps  according  to  choice. 

Aftertreatment  and  cure  are  given  under  subtotal  hysterectomy  below. 

Subtotal  Hysterectomy.- — At  least  one  ovary  should  be  normal  and 
the  woman  young  in  the  selection  of  case  so  that  ovulation  and  men- 
struation are  of  paramount  importance.    Thus  one  or  both  annexa  as 


576  GONOCOCCAL  INFECT  10. \  I.\  THE  FEMALE 

wholes  may  hv  norinal  hut  the  uterus  alone  the  seat  of  profound 
gonococcal  metritis.  In  the  technic  all  details  described  for  total  hys- 
terectomy are  (lu{)licated  down  to  the  sejia  rat  ions  about  the  uterus 
and  l)oth  annexa.  In  the  proper  case  sucii  adhesions  are  relatively 
much  less  manifest  than  in  total  hysterectomy.  The  tubes  and  o\aries 
are  carefully  inspected  and  even  if  only  one  ovary  is  macrosco])ically 
normal  it  is  left  and  all  the  other  annexa  removed.  Its  own  tube,  if 
normal,  may  be  si)ared  but  beiuij  useless  had  best  be  sacrificed.  The 
uterus  is  elevated  and  a  wedjj;e-shaped  i)iece  with  its  base  at  the  fundus 
and  its  apex  not  quite  reaching  the  cervix  is  removed.  P2ffort  to 
exclude  the  round  ligaments  is  made  and  in  deepening  the  incision 
toward  the  cervix  the  broad  ligaments  may  be  entered.  After  this 
segment  of  the  corpus  is  ablated  hemorrhage  is  arrested  with  clamp  and 
ligature  or  stitch.  The  incision  in  the  uterus  may  embrace  one  tube 
alone  or  both  tubes  and  one  ovary  with  one  or  both  tubes,  as  the  object 
is  to  spare  one  ovary  for  ovulation  and  the  lower  segment  for  the  uterus 
for  menstruation. 

Ajicrtrcaiincnt. — The  measures  are  the  same  for  both  classes  of 
hysterectomy.  The  patient  is  put  to  bed  and  according  to  indications 
stimulation,  elimination  and  sedation  are  applied  in  the  immediate 
aftertreatment.  The  Fowler  position  is  the  best  means  of  drainage. 
The  \aginal  gauze  is  remo^•ed  in  twenty-four  hours  and  the  suture 
line  is  inspected  on  the  fifth  or  sixth  day.  The  stitches  are  remcned 
on  the  seventh  or  the  ninth  day.  FaAorable  cases  are  up  and  about  in 
about  two  weeks. 

The  question  of  drainage  must  be  determined  by  indications,  route 
and  material.  All  drains  are  omitted  unless  particularly  necessary. 
"^Vhen  in  doubt  do  not  drain"  is  the  new  dictum,  reversing  the  old 
contrary  one.  Abscess  cavities  not  removed,  l\Tnph  accumulations, 
obvious  possible  sources  of  infection,  and  damaged  and  repaired 
viscera  such  as  the  bladder,  bowel  or  rectum  are  the  indications.  The 
vagina  is  the  best  route,  and  the  material  may  be  rubber  tubing  in 
extreme  cases  but  cigarette  drains  in  average  cases,  both  being  com- 
bined with  light  gauze  packing  of  the  vagina.  Removal  of  the  drain 
occurs  on  the  fifth  or  sixth  day  if  not  adherent  in  the  dee])  field,  other- 
wise delay  is  had  for  it  to  loosen.  No  renewals  are  advisable  except 
perhaps  the  light  vaginal  gauze.  Douches  are  omitted  or  used  with 
caution  against  flooding  the  pelvis  through  the  drainage  canals  after 
breaking  adhesions  by  excess  of  pressure.  A'aginal  cleansing  by  the 
douche  is  alone  necessary,  which  may  be  secured  by  the  Fowler  position 
in  most  cases  without  any  drainage  immediately  after  the  operation 
and  without  douches  later. 

The  remote  aftertreatment  is  concerned  with  restoration  of  the 
bodily  health,  strength  and  function  and  with  attention  to  sequels  of 
the  gonococcus  in  the  externalia. 

Cnre. — Removal  of  the  uterus  and  appendages  of  course  ablates 
all  disease  so  far  as  these  organs  are  concerned  so  that  symptomatic 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVARIES         577 

cure  may  be  absolute  unless  other  sif^ns  of  th(;  disease  persist  in  anrl 
about  the  vagina,  vulva  and  urethra.  Pathologic  cure  is  impossible 
because  the  affected  organs  are  totally  sacrificed  and  lost  to  the 
physiology  of  the  body. 

The  bacteriologic  cure  means  removal  of  th(;  gonococci  in  any  i)art 
whatever  of  the  sexual  system,  which  includes  the  external  organs  after 
the  internal  organs  have  been  removed. 

GONOCOCCAL  INFECTION  OF  THE  TUBES  AND  OVARIES. 

Ssmonyms. — Pelvic  inflammation,  sali)ingitis,  ovaritis,  oophoritis, 
salpingoophoritis  and  annexal  disease  are  commonly  used. 

Definition. — Invasion  of  the  tubes,  ovaries  and  pelvic  peritoneum, 
individually  or  collectively,  by  the  gonococcus  alone  or  allied.  Almost 
invariably  the  order  of  involvement  is  that  of  the  tubes  first  and  the 
peritoneum  last. 

Type. — Gonococcal  invasion  of  these  organs  is  an  acute  infection, 
almost  invariably  followed  by  chronic  lesions.  The  contamination  is 
by  direct  continuity  and  contiguity  in  most  cases  and  very  rarely 
hematogenous  along  with  endocarditis  and  other  signs  of  systemic 
complications. 

Varieties. — The  usual  classification  may  be  made,  so  that  there  are 
recognized,  as  to  origin  gonococcal,  nongonococcal  and  associated 
infections;  as  to  course  acute,  subacute  and  chronic  and  as  to  sequels 
complicated  and  uncomplicated.  In  the  causal  relation  the  gonococcus 
predominates  and  authorities  vary  in  the  percentage  between  about 
20  per  cent,  and  about  70  per  cent.  The  later  authors  with  better 
methods  of  investigation  tend  toward  the  higher  proportions,  as  do 
those  in  whose  hands  all  the  elements  are  controlled  in  each  case. 
Gurd^  has  found  that  the  gonococci  are  more  common  in  the  scrapings 
of  the  abscess  wall  than  in  the  free  pus.  It  is  in  the  latter  that  most 
authorities  have  searched  for  the  organisms,  and  often  in  vain. 

As  heretofore  in  this  work  the  gonococcal  is  taken  as  the  t^'pe. 
Nongonococcal  lesions  occur  in  the  soil  made  favorable  by  the  gono- 
coccus or  their  organisms  may  accompany  it  at  the  outset,  causing 
mixed  or  associated  infections. 

:  Etiology. — The  infection  occurs  by  the  gonococcus,  which  travels  in 
continuity  of  surface  of  the  mucosa  and  in  contiguity  of  organs  such  as 
tube,  ovary  and  peritoneum  as  a  rule  but  as  an  exception  through  the 
lymphatic  and  bloodstream.  Primary  cases  are  unkno\sTL  although  it 
is  assumed  that  salpingitis  may  arise  from  the  action  of  toxins.  Second- 
ary types  are  virtually  the  only  ones  and  nearly  all  are  due  to  extension 
and  only  the  occasional  example  to  hematogenous  factors.  Unilateral 
cases  are  rare,  in  the  sense  that  one  tube  may  entirely  escape  while  its 
fellow  is  severely  compromised.    Bilateral  disease  is  the  rule,  although 

1  Jour.  Med.  Research,  1910,  xxiii;  new  series,  xviii,  151-175. 

37 


57S  GOXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

one  tube  may  be  severel\-  dainatjed  and  even  destroyed  while  its  fellow 
comparati\ely  escajx's  but  is  nevertheless  involved.  The  i>redisposing 
causes  are  the  same  as  those  in  any  other  disease,  catarrhal  diathesis, 
ill  health,  poor  habits  especially  as  to  alcohol  and  sexual  life,  exposure 
and  depreciating  occupation.  The  exciting  elements  are  the  gonococcus 
without  or  with  its  allies,  stimulated  to  extension  by  its  own  virulence, 
the  patient's  low  resistance  or  by  faulty  management  and  overactive 
treatment,  \iolent  examinations,  vigorous  instrumentations,  con- 
centrated applications  and  ill-advised  operations — all  chiefly  concerned 
with  endocervicitis  and  endometritis — are  extremely  important  factors 
in  leading  to  disease  in  the  appendages. 

Pathology. — The  gonococcus  as  in  every  other  organ  invades  and 
locates  at  first  on  the  surface  of  the  tube  and  later  bj^  penetration 
reaches  the  muscularis  and  peritoneum.  In  the  ovary  and  in  the 
peritoneum  adjoining  it  and  the  uterus  its  performance  is  much  the 
same,  at  first  superficial,  then  deep.  The  essence  of  the  process  through 
the  extenduig  and  penetrating  organisms  is  at  first  catarrhal  m  the 
early  stage  of  invasion,  promptly  suppurative  in  the  establishment 
and  in  the  decline  again  catarrhal  unless  there  are  complications  and 
sequels.  The  tissues  in\obed  are  in  accordance  with  these  steps  in  the 
tubes,  at  first  the  epithelial  and  subepitlielial  layers  of  the  mucosa  and 
glands  and  then  the  muscular  and  peritoneal  coats;  and  in  the  ovaries 
the  surface  epithelium  is  at  once  attacked  and  denuded,  adhesions  to 
adjoining  serosa  begin  and  later  penetration  and  denser  fixation  lead 
to  abscess  upon  and  within  the  organ;  and  in  the  peritoneum  the  same 
process  is  followed  until  wide  extent  and  great  depth  are  reached  with 
pocket  or  pockets  of  pus  and  flimsy  or  fibrinous  bands.  The  ovarian 
lesion  is  therefore  a  periovaritis  in  the  majority  of  cases.  True  abscess 
of  the  parench^Tiia  cf  the  OAary  is  rare.  These  facts  have  an  important 
bearing  on  the  treatment  and  are  the  basis  of  conservative  surgery  of 
the  ovary. 

The  temporary  lesions  are  much  the  same  .in  all  three  organs.  Exfoli- 
ation, desquamation,  mucus,  mucopus  and  pus  during  the  early  exuda- 
tive in^•asion  and  establishment,  followed  by  small  roimd-cell  infiltra- 
tion and  finally  by  decline  and  healing.  Total  absorption  of  exudate  is 
in  the  mild  cases  rare  and  the  flimsy  adhesions  may  disappear,  leaving 
little  or  no  changes.  The  rule,  is,  however,  for  permanent  lesions 
through  penetration  and  destruction.  In  the  tubes  the  exfoliation  and 
small  round-cell  infiltration  lead  to  superficial  or  deep  ulceration,  cellu- 
lar substitution,  scar  formation  and  deformity  of  the  caliber.  On  its 
surface  duplicate  lesions  produce  adhesions.  The  ovaries  and  peri- 
toneum pass  through  the  same  experience  and  usually  show  few  or  many 
dense  adhesions  which  do  not  absorb  and  which  in  any  lawless  manner 
may  bind  the  elements  of  one  appendage  to  themselves,  to  the  uterus, 
to  its  fellow  and  to  the  surrounding  serosa.  The  entire  pelvic  contents 
may  be  involved  in  these  adhesions.  The  associated  lesions  are  the 
antecedent  foci  from  which  the  extension  proceeded,  which  are  almost 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVARIES 


579 


invariably  gonococcal  endocervicitis  and  endometritis  with  infection 
still  lower  in  the  sexual  canal.  The  complicating  lesions  are  systemic 
involvement  by  absorption  and  bacteremia  and  direct  involvement  of 
the  urinary  organs.  This  scientific  view  makes  all  the  other  gonococcal 
lesions  of  the  sexual  system  one  disease  by  the  process  of  traveling  from 
point  to  point,  and  not  as  complicatic^ns  of  any  initial  major  lesion,  as 
urethritis  is  in  the  male.  The  bacterial  lesions  are  the  gonococci,  in 
pure  culture  or  mixed  with  their  allies,  the  usual  pyogenic  germs.    The 


Fig.  127. — Right  and  left  pyosalpinx.  Adhesions  to  uterus,  rectum  and  vermiform 
appendix.  Co,  colon;  C,  cecum;  R,  rectum;  Rt,  right  Fallopian  tube;  Lt,  left  Fallopian 
tube;  U,  uterus.     (Dudley.^) 


free  pus  of  abscesses  is  often  sterile  of  the  gonococcus  and,  as  just  stated, 
recent  observers  have  found  that  the  tissue  of  the  abscess  wall  does  con- 
tain them  when  the  pus  is  sterile.  The  gonococcus  prepares  the  soil 
for  the  invasion  of  other  organisms  even  after  it  has  seemmgly  or 
actually  disappeared.  As  in  urethritis  its  common  associates  are  the 
Streptococcus  pyogenes,  the  Staphylococcus  pyogenes  and  the  Bacillus 


*  Loo.  cit. 


580  GOXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

coli  communis.    Tlie  Bacillus  tuberculosis  is  rare  but  very  important 
in  its  secondary  relations  to  the  ijonococcus  in  the  sexual  orfjans. 

Symptoms.-  Subjective  and  objective  forms,  local  and  general  mani- 
festatit)ns  all  varying  according  to  the  stages  of  invasion,  establishment 
and  termination  are  recognized. 

The  general  type  is  determined  by  the  local  and  general  resistance, 
the  virulence  of  infection,  the  progress  from  point  to  i)oint,  and  the 
condition  of  freedom,  ])atency  and  oozingof  the  tube  as  contrasted  with 
fixation,  closin-e  and  retention.  The  length  of  antecedent  gonococcal 
infection  is  an  important  factor;  as  a  ride  the  more  recent  this  is  the 
more  ra])i(l  the  onset  and  the  more  ^•iolent  the  course  of  the  pelvic 
comi)lications.  There  are  no  pathognonu)nic  symptoms  of  tubal, 
ovarian  and  peritoneal  lesions  apart  from  each  other.  The  acute  and 
chronic  classification  is  the  best. 

Gonococcal  Acute  Infection  of  the  Tubes  und  Ovaries. — The  usual 
stages  of  invasion,  establishment  and  termination  are  of  great  im])()r- 
tance.  The  invasion  may  be  sudden  and  sharp  or  more  commonly  slow 
and  indefinite.  It  is  often  related  with  menses,  childbirth,  miscarriage 
and  faulty  office  treatment  for  leucorrhea,  dysmenorrhea,  sterility  or 
suspected  gonococcal  disease.  Fresh  relai)se  of  gonococcal  foci  lower 
in  the  sexual  organs  is  an  important  element,  especially  endometritis. 
In  the  local  signs,  there  is  often  decrease  or  cessation  of  uterine  dis- 
charge in  the  earliest  hours  of  the  disease  exactly  as  in  the  male  a 
urethritis  temporarily  improves  during  the  onset  of  testicular  or  pros- 
tatic complications.  The  bladder  and  rectum  are  disturbed  by  the 
direct  irritation  of  proximate  inflammation  and  by  reflex  stimulation  or 
inhi})ition.  There  may  therefore  be  frequency  and  pain  in  both  organs 
or  delayed  activity.  The  constitutional  signs  of  pus  and  infection  vary 
with  the  intensity  of  the  process.  Variously  related  are  chilliness  or 
chill,  malaise  or  prostration,  fever  from  nearly  normal  to  about  103°  F. 
with  moderate  variations,  acceleration  of  pulse,  moderate  or  severe, 
sweating,  anorexia,  nausea  or  vomiting,  diarrhea  or  constipation.  Rest 
in  bed  is  welcDme  and  the  blood  count  shows  leukocytosis. 

In  the  establishment  the  condition  is  determined  by  the  freedom, 
patency  and  drainage  of  the  tube  so  that  it  oozes  pus  intermittently 
upon  the  peritoneal  surface  or  into  the  uterus  or  by  the  fixation,  closure 
and  retention  of  the  tube  so  that  the  pus  accumulates  and  distends 
the  tube.  The  former  is  a  condition  of  extension  and  relapses  and  the 
latter  rather  one  of  protection.  Unilateral  and  bilateral  diseases  also 
determine  the  severity. 

The  s>Tnptoms  are  subjective  and  objective,  local  and  systemic. 
In  the  local  subjective  s\Tnptoms  are  found  sensory,  vaginal,  functional, 
vesical  and  rectal  elements.  The  sensory  signs  are  more  severe  than 
those  of  metritis,  located  rather  diffusely  than  centrally  over  the  womb, 
constant  like  those  of  any  other  abscess  or  pus-formation,  often  throb- 
bing with  little  remission,  increased  by  exertion,  constipation,  physical 
examination  and  intercourse  (should  the  latter  in  folly  be  attempted) 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVARIES         581 

and  finally  decreased  by  rest  in  bed  and  careful  regulation  of  defecation 
and  urination.  The  vaginal  signs  continue  those  of  the  antecedent 
gonococcal  lesions  of  vagina,  cervix  and  uterus.  After  the  first  few 
hours  of  decrease  the  discharge  is  resumed  and  often  augmented, 
making  the  condition  duplicate  that  of  gonococcal  acute  vaginitis  and 
endometritis.  Functional  disorders  are  increased,  decreased  or  abol- 
ished menses  according  to  the  ovarian  lesion  and  reaction  thereto. 
The  tendency  is  toward  irregular  menorrhagia  and  even  metror- 
rhagia. 

The  vesical  signs  arise  from  pressure  of  the  enlarged  and  displaced 
uterus  and  the  traction  of  adhesions  to  the  uterus  and  its  appendages  and 
from  circulatory  and  nervous  excitement  or  depression.  The  latter  are 
seen  in  the  very  early  periods,  if  at  all,  while  the  former  occur  in  the 
subsequent  course.  There  are  therefore  frequency,  dysuria  and  tenes- 
mus or  retention  followed  by  dysuria  and  tenesmus.  Normal  urine 
proves  an  uninfected  bladder.  The  rectal  elements  have  the  same 
factors  in  constipation,  tympanites  and  pain.  Congestion,  nervous 
disturbance  and  pressure  of  the  heavy  and  adherent  uterus  interfere 
with  normal  evacuation,  which  in  turn  causes  gaseous  indigestion  and 
tympanites.  All  the  factors  are  concerned  in  the  pain.  All  these 
symptoms  may  also  be  due  to  the  peritonitis  without  reference  to  the 
mechanical  conditions. 

The  systemic  subjective  symptoms  continue  those  of  the  invasion 
and  are  highly  various  in  type  according  to  the  severity  and  progress 
of  the  disease.  In  mild  cases  they  may  be  nearly  absent  and  in  intense 
cases  they  may  simulate  general  peritonitis  and  septicemia.  The 
middle  ground  of  these  extremes  is  occupied  by  a  wdde  assortment  of 
cases. 

The  objective  symptoms  are  also  local  and  systemic  and  chiefly 
corroborate  the  subjective  syndrome.  In  the  local  signs  bimanual, 
vaginal  and  rectal  examination  are  painful  and  dangerous  lest  pockets 
of  pus  be  ruptured.  A  small  speculum  should  be  used,  if  any  at  all. 
The  antecedent  gonococcal  lesions  must  be  demonstrated  in  the 
urethra,  vulva,  vagina  and  uterus  with  foresight  as  to  stimulating 
extensions.  The  uterus  must  first  be  recognized  as  the  landmark.  It  is 
enlarged,  soft,  tender  and  more  or  less  fixed.  Traction  or  pressure 
away  from  the  point  of  fixation  toward  restoration  to  its  normal 
position  is  very  painful.  Any  form  or  degree  of  displacement  may  be 
present  above  the  level  of  the  pelvic  floor.  The  cervix  is  soft,  patent 
and  discharges  pus  into  the  speculum  and  upon  the  finger. 

In  the  vagina  one  or  both  lateral  fornices  are  tender  and  boggj^  and 
the  posterior  fornix  may  be  filled  w^ith  an  indefinite  or  definite  tumor 
varying  in  size  from  barely  perceptible  thickening  to  a  mass  of  lemon 
or  cocoanut  size  reaching  above  the  pelvic  brim.  In  the  acute  period 
outlines  are  difficult  and  persistence  of  manipulation  is  very  dangerous. 
It  is,  therefore,  sufficient  to  recognize  the  fact  of  involvement  rather 
than  its  precise  pathogenesis. 


582       GOXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

111  the  toriniiiatioii  only  the  mild  cases  subside  leavinu'  tew  symptoms 
behind,  ehielly  of  fimetional  diaraeter  with  sterility  foremost.  The 
majority  of  eases  throufjh  the  delicacy  and  complexity  of  the  tissues 
and  organs  involved  pass  at  once  into  the  chronic  stage.  Of  these 
many  have  a  protracted  course,  profimd  complications,  severe  sequels 
and  few  esca])e  without  virtual  unsexing  and  chronic  invalidism. 

Gonococcal  Chronic  Infection  of  the  Tu})Cft  and  Ovaries. — The  majority 
of  acute  attacks  become  chronic  through  the  nature  of  the  disease  and 
the  anatomy  of  the  parts.  The  usual  classes  of  subjective  and  objective, 
local  and  systemic  symptoms  are  recognized  but  the  three  periods  of 
invasion,  establishment  and  termination  cannot  be  outlined  because 
the  invasion  consists  in  the  acute  attack  and  the  disease  is  seen  in  full 
establishment  for  a  few  weeks  or  even  many  months. 

The  general  type  depends  on  the  activity  of  the  acute  antecedent 
and  on  the  sequels  it  has  ])ro(luced.  Unilateral  and  bilateral  disease 
are  factors,  likewise  the  tubal,  tuboovarian  and  peritoneal  forms.  The 
forerunning  uterine  lesion  likewise  changes  the  picture.  Cases  are  seen 
whose  symptoms  are  more  or  less  stationary  without  much  progress, 
but  others  which  slowly  progress  with  relapses  and  exacerbations 
produced  by  motion,  accident,  intercourse,  examination,  treatment, 
spontaneous  rupture  of  the  tube,  secondary  infection  often  of  the 
hematogenous  type,  or  by  menses,  childbirth  and  miscarriage. 

The  local  subjective  symptoms  are  sensory,  functional,  intestinal, 
urinary  and  peritoneal.  The  sensory  signs  are  due  to  pressure,  adhe- 
sions, menses  and  backache.  The  pressure  of  the  enlarged,  displaced 
and  adherent  womb  on  surrounding  organs  and  its  tug  on  the  adhesions 
account  for  much  of  the  pain.  Dysmenorrhea  of  the  chronic  conges- 
tion, endometritis  and  malposition  are  often  almost  unbearable.  The 
backache  arises  from  all  three  factors.  The  functional  disorders  are 
exudative,  menstrual,  sexual  and  reproductive.  Leucorrhea  from  the 
endometritis  and  vaginitis  and  at  times  from  a  leaking  tube  may  be 
most  inconvenient.  The  congestion  of  the  infection  and  fixation  of  the 
womb  excite  menorrhagia,  metrorrhagia  and  dysmenorrhea  and  the 
same  factors  combined  with  decrease  in  the  size  of  the  vagina  produce 
dyspareunia.  Sterility  is  invariable  in  all  marked  cases.  Such  women 
have  one  child  and  no  more  or  none  at  all  in  accordance  with  the  period 
of  wedlock  in  which  they  acquire  gonococcal  disease. 

The  intestinal  signs  are  pain,  constipation,  indigestion  and  appendi- 
citis. The  pain  is  due  to  adhesions  to  the  rectum  or  to  the  pressure 
and  pull  of  the  feces  on  the  conglomerate  mass  within  the  pelvis. 
Constipation  may  be  partly  voluntary  through  fear  of  the  pain  but  is 
chiefly  reflexed.  Pressure  of  the  pelvic  mass  upon  the  rectum  causes 
obstipation,  often  of  marked  degree.  The  various  factors  lead  to  gase- 
ous indigestion  and  the  appendix  through  direct  in\'olvement  may  give 
its  train  of  symptoms.  The  urinary  s^inptoms  are  often  those  of 
cystitis — pollakiuria,  tenesmus  and  reflex  retention — more  marked 
while  other  symptoms  are  augmented.    Cystitis  is  ruled  out  by  recog- 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVARIES         583 

nizing  that  the  urine  is  normal.    Cystos(;o[)y,  if  perfcjrrned,  requires 
most  careful  antiseptic  toilet  of  tlie  bladder  immediately  afterward. 

The  peritoneal  syndrome  is  one  of  relapsing  iK;lvic  inflammation, 
frequent  and  moderate  rather  than  rare  and  severe.  'J'his  is  called 
"prostitute's  colic"  and  is  due  to  small  fresh  foci  of  infection  or  to  the 
dragging  of  adhesions.  The  latter  gives  this  class  of  patient  almost 
constant  bearing  down  and  frequent  sharp  pain.  Materially  lowered 
health  is  the  outcome.  While  these  symptoms  are  techni(;ally  j)eri- 
tonealjthe  tubes,  ovaries  and  serosa  are  all  combined  in  their  production. 

The  systemic  subjective  symptoms  are  thermic  and  hemic  and  may 
be  negative  except  during  exacerbation.  The  fever  is  slight  or  absent 
while  the  process  is  at  a  standstill  but  is  manifested  in  any  progress  of 
it.  The  blood  count  is  negative  for  pus  unless  a  new  extension  is  inci- 
dent. The  pulse  in  rate  and  quality  follows  the  same  rule.  Absorption 
of  the  toxic  products  and  the  persistent  drain  of  the  other  symptoms 
lead  to  anemia,  prostration,  depreciation,  loss  of  weight,  muscular 
and  nervous  stability. 

The  objective  symptoms  are  also  local  and  systemic,  of  which  the 
latter  verify  those  described  by  the  patient.  The  physical  examina- 
tion embraces  the  external  and  internal  genitals,  and  in  the  former 
prove  the  gonococcal  infection.  The  uterus  is  the  landmark  of  the 
internal  organs  and  shows  in  addition  to  the  enlargement,  tenderness 
and  softening  of  the  chronic  endometritis  and  metritis,  fixed  malposition 
and  decreased  mobility.  Attempt  to  replace  the  organ  or  to  move  it 
away  from  the  point  of  maximum  fixation  excites  pain.  In  the  vagina 
on  bimanual  examination  one  or  all  of  the  fornices  are  found  invaded, 
most  commonly  the  posterior  with  the  right  or  left  or  both,  and  less 
frequently  the  anterior  also.  The  mass  is  directly  or  laterally  behind 
the  uterus,  of  variable  and  indefinite  form,  commonly  of  extensive  size 
and  in  consistency  tense,  fluctuating  or  boggy  according  to  the  quantity 
and  quality  of  the  contents  and  the  character  of  smTounding  adhesions. 
The  mass  is  usually  sensitive  through  embodiment  of  the  ovary  and 
tugging  on  the  adhesions.  The  size  may  be  too  small  for  definite  diag- 
nosis without  an  anesthetic.  The  rule  is  moderate  enlargement  but 
extreme  cases  filling  the  pelvis  are  not  uncommon.  Sole  tubal  disease 
is  rare  as  the  ovaries  are  usually  compromised.  In  fact,  fixed  and 
immobile  ovary  may  be  regarded  as  significant.  Unilateral  conditions 
are  also  uncommon.  The  more  recent  the  case  the  more  apt  it  is  to  be 
unilateral  and  the  greater  the  caution  during  examination.  Older 
cases  especially  with  relapses  are  almost  always  bilateral. 

Gofiococcal  Relapsing  Infection  of  the  Tubes  and  Ovaries. — The  factors 
responsible  are  chiefly  leakage,  traumatism  and  new  uifection.  The 
oozing  may  take  place  upon  the  peritoneal  surface  or  into  the  uterus, 
causing  "salpingitis  profluens,"  but  tliis  condition  is  more  common 
in  serous  or  catarrhal  lesions  which  have  few  or  practically  no  adhesions. 
The  trauma  may  occur  durmg  examinations,  treatments,  accidents, 
physical  exertion  and  coitus.    Objective  diagnosis  and  treatment  rest 


584  GONOCOCCAL  lyFECTIOX  IX  THE  FEMALE 

^vitll  the  physician  and  promiscuous  investigation  of  lesions  and  appli- 
cations are  to  be  avoided.  Mishaps  are  beyond  control  but  muscular 
strain  and  coitus  belong  to  the  ]iatient's  own  care  of  herself.  New 
infections  are  those  with  the  gonococcus  such  as  are  ctnumon  in  prosti- 
tutes or  with  mixed  organisms  through  the  bloodstream  and  lymph- 
stream.  The  Bacillus  coli  is  the  most  connuon  in  these  circumstances 
and  ma\-  reach  the  sac  also  through  adhesions  directly  to  the  rectum. 

The  acute,  chronic  or  rela])sing  forms  of  infection  of  the  tubes  and 
ovaries  are  rarely  fatal  directly  if  the  gonococcus  is  the  only  organism. 
The  cases  are  mild,  moderate  or  severe.  The  mild  cases  are  the  rarest 
and  resorb  the  exudate  partially  or  totally,  leaving  behind  displace- 
ments, functional  disorder,  sterility  and  fair  health.  This  outcome  is 
apt  to  ai)])ear  in  patients  infected  at  or  near  the  menoj)ause.  Hydro- 
salpinx with  sterile  contents  may  belong  to  this  class  of  cases,  although 
on  histologic  grounds  this  has  been  disputed  by  IMenge^  and  others, 
who  claim  that  a  pyogenic  process  cannot  retrograde  into  the  condition 
of  hydrosalpinx.  The  moderate  cases  may  be  called  the  stationary 
forms  and  have  chronic  invalidism,  pahi,  anemia,  intestinal  disorder, 
myasthenia,  neurasthenia,  fmictional  disorder  and  sterility.  The 
severe  lesions  may  be  called  the  progressing  and  i  elapsing  cases,  having 
even  extragenital  and  systemic  involvements.  The  tubes  may  rupture 
spontaneously  into  the  peritoneal  cavity,  bowel,  })ladder,  broad  liga- 
ment or  uterus.  Upon  the  serosa  the  pus  repeats  all  the  former  picture 
and  threatens  a  general  peritonitis  and  septicemia.  In  the  bowel  the 
pus  causes  proctitis,  at  first  acute,  then  chronic,  from  the  persistent  or 
intermittent  evacuation.  A  sinus  ensues  which  is  kept  active  by  pus 
from  the  tube  and  by  the  feces  from  the  rectum.  Mixed  infection 
always  occiu"s  ascending  from  the  rectiun.  The  same  sequels  of  event 
may  occur  with  reference  to  the  bladder.  In  the  broad  ligament  the 
pus  travels  downward  in  the  cellular  planes  and  presents  at  the  vagina 
or  upward  along  the  round  ligament  and  points  at  the  inguinal  region. 
In  the  uterus  the  pus  causes  intermittent  and  copious  leucorrhea  in 
which  it  is  itself  the  chief  constituent. 

Diagnosis. — Includes  the  fact  of  gonococcal  involvement  and  the 
kind  of  tubal  and  ovarian  disease  and  the  various  other  lesions  through 
which  confusion  may  arise.  The  usual  four  elements  of  history,  symp- 
toms, laboratory  investigations  and  treatment  apply. 

Among  the  most  important  is  the  factor  of  history.  The  age  is 
usually  early  in  sexual  development  and  the  civil  condition  either 
married  to  a  man  known  to  be  or  known  to  have  been  a  roue.  The 
woman  may  be  of  loose  morals,  admitted  or  suspected.  Underpaid 
occupation  leads  young  women  into  temptation.  Among  the  symptoms 
are  those  of  the  antecedent  acute  urethritis,  vaginitis,  endometritis, 
leucorrhea,  dysmenorrhea  and  the  like  arising  soon  after  such  a  mar- 
riage, or  after  loose  sexual  relations.    Correlated  with  the  symptoms  of 

»  Centralbl.  f.  GyiiiikoL,  189.5,  xix,  796-801. 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVA  HI  EH         585 

tubal  extension  is  a  menstrual  period,  a  childbed  fev(;r,  miscarriage  or 
a  new  infection  after  intercourse.  Previous  good  Ixxliiy  and  sexual 
health  followed  by  the  syndrome  of  external  goiiocf)Ccal  disease  and  by 
the  invalidism  with  which  the  woman  presents  herself  is  important. 
Menstrual  activities,  normal  at  first,  later  irregular  and  painful  in 
the  flow  with  pus  and  a  tumor  are  the  next  step.  Sterility  following  one 
childbirth  or  without  conception  is  of  grave  meaning,  especially  if  the 
woman  has  never  had  menstrual  or  sexual  disorder.  The  subjective 
story  of  the  invasion  with  its  active  sickness  and  the  establishment  with 
its  systemic  reaction  and  the  local  manifestation  of  pus  formation  in 
the  sensory,  vaginal,  functional,  vesical  and  rectal  signs.  The  objec- 
tive examination  through  the  vagina  and  rectum  explores  and  identifies 
uterus,  tubes,  ovaries  and  pelvis  and  establishes  antecedent  foci  in  the 
lower  sexual  tract.  The  laboratory  examination  will  show  the  blood 
count  of  pus  in  the  acute  stage  and  any  fresh  outbreak  of  the  chronic 
stage.  The  gonococcal  complement  fixation  test  is  positive  in  most 
long-standing  cases.  The  gonococci  will  be  found  in  smear  and  culture 
or  in  any  postoperative  specimen.  In  the  treatment  all  the  expectant 
methods  known  to  avail  during  gonococcal  disease  are  an  indirect 
aid.  Often  specimens  secured  during  treatments  are  most  valuable. 
Laparotomy  alone  will  furnish  the  exact  anatomical  diagnosis. 

COMPAEATIVE   SYNDKOME    OF   SALPINGITIS    (DUDLEY^). 

Catarrhal  Salpingitis.  Purulent  Salpingitis. 

1.  Fever  present  in  acute  stage  and  1.  Fever  high  in  acute  stage.  Usually 
usually  absent  in  chronic  stage.                               slight    evening    temperature    in    chronic 

stage.  If  pus  becomes  sterile,  tempera- 
ture may  be  normal. 

2.  Pain  in  region  of  tube  variable  in  2.  Pain  and  systemic  disturbance 
acute  stage;  usually  absent  or  almost  (anxious  facies,  nausea,  depression)  more 
absent  in  chronic  stage.                                            pronounced '  in   acute    stage.      Pain   and 

general  malnutrition  usually  present  in 
chronic  stage.  Symptoms  partly  due  to 
extention  of  infection  to  neighboring 
organs,  producing  ovaritis,  pehdc  peri- 
tonitis and  cellulitis. 

3.  Salpingitis  profluens  not  uncommon.  3.  Salpingitis  profluens  uncommon. 

Differential  Diagnosis.  —  Gonococcal  tubal  infection  must  be  dis- 
tinguished from  other  forms  and  likewise  other  pelvic  lesions  giving 
similar  symptoms.  The  chief  other  forms  are  catarrhal,  suppurative 
and  tuberculous  and  the  table  on  page  586  shows  the  most  important 
differences.  In  general  suppurative  pelvic  infection  secondary  to  itself 
in  the  lower  genital  tract  is  practically  indistinguishable  from  the 
gonococcal  form  except  in  the  laboratory  investigation,  in  its  much 
more  frequent  relation  with  miscarriage  and  childbirth  and  m  its  more 
violent  course,  shorter  duration  and  tendency  to  rapidly  serious  out- 
come. 

1  Log.  cit.,  p.  262. 


586 


GONOCOCCAL  INFECTIOX  IX  THE  FEMALE 


FORMS  OF  TUBAL  AND   OVARIAN'  DISEASE. 


Symptoms. 

Gonococcal. 

Catarrhal. 

TuberoulouB. 

Age. 

Sexual    maturity    as    a 
rule. 

Early    or    any. 

Early  or  any. 

Civil  condition. 

Wedlock  or  prostitution. 

Children    ami    vir- 

Children   and    vir- 

gins. 

gins. 

Systemic      disturb- 

During acute  stage. 

None  or  verj- slight. 

Progressing  with  the 

ance  (.nausea,  de- 

disease. 

pression, anxiety)  . 

Invalidism  (malnu- 

During chronic  stage. 

None. 

Progressing  with  the 

trition  and  suffer- 

disease. 

ing)  . 

Pain. 

Severe     during     acute. 

During  acute  stage. 

Severe  and  constant 

constant   or  relapsing 

absent  in  chronic 

soiiiotinies       with 

during  chronic  stage. 

period. 

rubbinfi;  sensations 
and  sounds. 

Salpingitis  profluens. 

Occasional    and    puru- 

Frequent and  ser- 

Absent        through 

lent. 

ous. 

atresia. 

Weakness. 

Moderate      in      acute, 

Very   moderate   or 

Progressive         and 

marked     in      chronic 

absent. 

rapid. 

cases. 

Fever. 

Active  low  range  during 

Moderate      during 

Afternoon  hectic  in 

acute,    moderate    and 

acute,  absent  dur- 

. type. 

variable  during  chronic 

ing  chronicperiods. 

stage,    absent    during 

sterile  pus  in   tube. 

Pyosalpinx. 

Moderate  or  marked. 

None. 

Moderate  and  late 
after    atresia. 

Pelvic    cellulitis. 

Moderate. 

None. 

Marked. 

Spleen. 

Not  affected. 

Not  affected. 

Enlarged. 

Other       abdominal 

Not  affected. 

Not  affected. 

Often  tuberculous. 

\dscera. 

Rubbing  sounds  and 

Absent. 

Absent. 

Sometimes  present. 

free  fluid. 

Other  lesions. 

Gonococcal     in     lower 

Catarrhal  in  lower 

Tuberculosis     in 

sexual  tract. 

sexual  tract. 

lungs,  etc. 

Organisms   in   exu- 

Gonococci. 

Micrococcus        ca- 

Bacillus    tubercu- 

dates. 

tarrhalis. 

losis     (occa.sion- 
ally). 

Coitus  as  source. 

Usual. 

Rare. 

Rare. 

Dudley^  gives  the  following  table  of  distinction  between  sactosalpinx 
and  other  inflammatory  and  noninflammatory  pelvic  disease.  Inas- 
much as  gonococcal  infection  occasionally  follows  the  type  of  sactO' 
salpinx  the  comparisons  are  worth  while  here. 


S.^.CTOSALPINX. 

Septic  condition  and  pain. 

Commonly  Vjilateral. 

Tube  oblong  and  tortuous. 

Commonly  adherent. 

Ovary  often  palpated  and  distinguished. 

Usually  not  larger  than  fist. 

Leukocytosis  usual. 

Sactosalpinx. 
Common. 
Usually  bilateral. 
Sensitive  to  pressure. 
Usually  fixed. 
Elastic  or  fluctuating. 
Result  of  infection. 


Cystic  Ovarian  Tumor. 
Absent. 

Commonly  unilateral. 
Spheroidal  or  spherical. 
Less  commonly  adherent. 
Tumor  is  diseased  ovary. 
May  grow  to  enormous  size. 
No  leukocytosis  unless  infected. 

Solid  Tumor  of  Tube. 
Rare. 

Usually  unilateral. 
Not  sensitive. 
Usually  free  and  mobile. 
Firm  consistence. 
Cause  unknown. 


'  Principles  and  Practice  in  Gynecology,  6th  Ed.,  191.3,  p.  265. 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVARIES 


587 


Sactosalpinx. 

circumscribed    and 


of 


Not  a  reliable 


Usually    sharply 

rounded  contour. 
Commonly  bilateral. 
Elastic  and  fluctuating 

sign. 
Position  relative  to  uterus:  mass  usually 

higher  in  pelvis  near  fundus  uteri;  not 

connected  with  cervix.     Vaginal  vault 

not  depressed. 

Sactosalpinx. 

Mass  usually  elastic;  may- fluctuate. 
Adhesions  common. 
Sensitive  to  pressure. 
Uterine  end  of  tube  enlarged. 

History  of  infection. 


Sactosalpinx  (Right  Side) 
Tumor  felt  by  vaginal  touch. 


After  acute  stage,  size  of  tumor  may  not 
materially  diminish. 

Recurrence  less  dangerous  and  less  fre- 
quent. 

Gastro-intestinal  disturbances  somewhat 
marked. 


Pelvic  Cellulitis. 

circumscribed;     may     be 


Not     sharply 

flattened. 
Commonly  unilateral.  ' 
Less  elastic  and  fluctuating 


Not  reliable. 


Position  relative  to  uterus:  usually  lower 
in  pelvis,  often  closely  connected  with 
uterus.  Vaginal  vault  commonly 
depressed. 

Tubal  Pheonancy. 

Consistence  often  quite  firm. 

Less  common. 

Not  sensitive. 

Commonly    normal    except    inter.stitial 

tubal  pregnancy. 
History  of  pregnancy: 

(a)   Amenorrhea. 

(6)   Increase  in  size  of  uterus. 

(c)  Enlargement  of  breasts. 

(d)  Morning  sickness. 

(e)  Rupture  of  tube  with  great  pain, 

collapse  (pelvic  hematocele), 
uterine  hemorrhage  and  dis- 
charge of  decidual  membrane. 

Appendicitis. 

Tumor  not  usually  within  reach  of 
vaginal  touch  but  is  felt  or  is  tender 
to  pressure,  on  external  palpation  in 
region  of  McBurney's  point. 

After  acute  stage,  tumor  apt  to  disappear. 

Recurrence   more    dangerous   and   more 

frequent. 
Decidedly  marked. 


Other  lesions  with  one  or  two  elements  resembling  tubal  and  ovarian 
disease  are  uterine  malpositions,  fecal  accumulations,  adherent  intestine, 
intestinal  tumors,  visceroptosis  and  skeletal  tumors.  The  points  for 
memory  in  these  lesions  follow.  The  sound  used  cautiously  will  prove 
any  uterine  displacement.  Fecal  impaction  is  revealed  by  digital 
examination,  colonic  palpation  above  the  pelvis,  the  proctoscope,  enema 
and  catharsis.  Intestinal  adhesions  and  kinks  are  demonstrated  by  the 
bismuth  test  and  the  a'-ray,  the  proctoscope  and  uterine  exploration. 
Intestinal  neoplasms  have  the  same  positive  proof.  Enteroptosis  varies 
with  changes  in  the  attitude  of  the  patient,  mobility  of  the  tumor,  func- 
tional disturbances  of  the  organ  involved,  the  bismuth  meal  and  the 
a:-ray  for  gastro-intestinal  descent,  pyelography  and  the  shadow  cath- 
eters for  the  kidneys.  Skeletal  tumors  have  bony  hardness  and  fixation 
through  vagina  and  rectum  and  essential  .I'-ray  findmgs. 

Treatment. — All  details  are  determined  by  acuteness,  chronicity  and 
complications.  Uncomplicated  cases  are  rare  and  require  the  same 
general  treatment  with  less  frequency  of  major  operation.  It  is 
understood,  therefore,  that  the  average  complicated  pictm'e  is  the 
one  referred  to  in  the  following  paragraphs. 


5SS  GONOCOCCAL  IXFECTIOX  I\  THE  FEMALE 

(.nuiucoccal  Acute  Infection  of  the  Tubes  and  Ovaries. — In  the  strict 
sense  prophylaxis  is  not  possible  beyontl  good  nitmagenient  and  treat- 
ment of  all  the  possible  antecedent  gonoeoeeal  lesions  in  order  to  pre- 
vent their  extensions  to  other  parts  and  finally  to  the  tubes  and  ovaries. 
Abortive  measures  are  in  the  nature  of  things  impossible. 

The  reader  is  referred  to  Chapter  IX  on  General  l^-incii)les  of 
Treatment  on  page  4S3  for  data  of  management. 

In  the  physical  measures  the  management  of  Simpson'  may  be  classed. 
It  ct)nsists  in  rest  in  beil,  open  bowels,  skin  and  kidneys,  light  diet, 
water  drinking  and  the  application  of  heat  or  cold  through  bags  or  coils 
applied  to  the  abdomen  and  douches  given  througli  the  vagina.  Mas- 
sage in  the  early  period  is  forbidden  and  includes  frequent  physical 
examinations,  lest  tramiia  be  given  the  pelvic  organs  and  annexa. 
Even  in  the  later  chronic  periods  the  abdomen  must  not  be  invaded  by  a 
general  massage  which  is  ad^•isable  for  its  passive  muscular  exercise  in 
the  body  as  a  whole  and  is  of  much  benefit.  In  hydrotherapy  heat  and 
cold  are  available  and  chosen  solely  in  accordance  with  comfort  and 
reaction.  The  tendency  is  to  try  cold  during  the  most  acute  days  and 
heat  later,  because  cold  usually  soothes  the  pain  while  the  heat  stimu- 
lates inactive  circulation  and  deficient  absorption.  The  bags  or  coils 
may  be  laid  on  the  abdomen  and  if  heat  is  used  it  may  be  slowly  aug- 
mented up  to  tolerance.  This  is  particularly  true  in  the  douches  which 
without  force  at  all  times  may  be  begun  with  low  and  advance  to  dis- 
tinctly high  temperature.  The  quantity  must  be  copious  because  dura- 
ation  during  application  counts  most.  The  technic  is  described  under 
this  subject  in  \aginitis.  Sitting  and  body  baths  have  the  usual 
indications  but  cannot  be  employed  before  the  patient  may  be  safely 
moved.  Posture,  especially  for  drainage,  has  already  been  described  in 
endometritis  and  metritis  but  must  usually  wait  until  symptoms  begin 
to  subside.  The  knee-chest  position  is  said  to  prevent  dense  adhesions. 
Lying  on  the  face  may  do  so  during  the  first  few  days,  if  tolerated, 
until  the  knee-chest  position  may  be  employed  in  the  later  periods. 
Alcohol  rubs  are  of  value  in  keeping  down  fever  and  controlling  sweats. 

The  medicinal  measures  are  systemic  and  local.  The  systemic  admin- 
istration is  chiefly  of  opiates  by  mouth,  needle  or  suppository  for  pain, 
nervousness  and  fear  and  for  limiting  peristalsis  in  early  peritonitis. 
Gastric  sedatives  are  given  for  nausea  and  vomiting.  Cathartics  should 
be  used  sparingly  in  order  not  to  excite  the  peritonitis.  There  must  be 
neither  constipation  nor  diarrhea  on  account  of  the  straining  in  each  and 
the  tenesmus  in  the  latter.  Diuretics  and  diaphoretics  are  all  of  the 
simple  kind  and  none  is  better  than  the  drinking  of  mineral  or  plain 
water.  Supportives  of  the  circulation  and  nervous  strength  are  impor- 
tant. Among  the  antispasmodics  atropine  is  first  and  liberally  given, 
as  it  is  a  good  cardiovascular  stimulant  and  quiets  the  smooth  muscle- 
fiber  of  the  intestines.  The  drying  afterefi'ects  are  controlled  by  the 
water  drinking.     Schindler^  teaches  that  the  uterus  has  involuntary 

'  Jour.  Am.  Med.  Assn.,  1909,  liii,  p.  1173-1179. 
-  Arch.  f.  Gynakol.,  1909,  Ixxxvii,  607-642. 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVARIES         589 

muscular  activity  which  atropiii  abolishes  and  thus  (;xt(;nsion  of  the 
disease  is  limited.  Serumtherapy  may  be  tried,  but  as  in  other  diseases, 
so  in  gonococcal  lesions,  this  method  is  in  its  infancy.  The  serum  seems 
best  during  the  acute  periods  and  the  bacterin  is  the  choice  during  the 
later  stages  of  the  disease.  As  eliminants  colonic  instillations  after  the 
manner  of  the  Murphy  drip  or  repeated  small  enemata  retained  as  long 
as  possible  are  of  great  value  in  many  patients. 

The  local  administration  is  chiefly  that  of  douches,  as  already 
described  under  vaginitis.  In  these  douches  it  is  the  duration  and  the 
heat  of  the  douche  rather  than  the  contained  drug  which  are  of  value. 
Hence  they  should  be  given  by  a  skilled  nurse  in  the  most  approved 
fashion. 

The  surgical  measures  are  nonoperative  and  operative.  The  non- 
operative  means  are  summed  up  in  steps  already  described  on  page  .564 
and  in  expectant  measures  involved  in  waiting  for  the  acute  stage  to 
subside. 

The  operative  steps  are  rare  and  concerned  in  symptoms  of  active 
absorption  due  to  large  accumulations  of  pus.  Such  an  abscess  should 
be  freely  opened  where  safe  for  the  general  peritoneal  cavity  and  where 
drainage  will  be  absolute.  The  tendency  is  to  leave  the  wound  wide 
open  with  due  protection  against  protrusion  of  the  intestines.  In  general 
the  policy  is  to  delay  operation  until  the  disease  has  become  chronic. 
The  reasons  are  that  gonococcal  inflammation  is  more  rapidly  and  more 
fully  self-limited  than  ordinary  pyogenic  infection.  Adhesions  form, 
walling  off  the  disease  from  the  general  peritoneal  cavity  so  that  evacu- 
ation or  other  treatment  becomes  decidedly  safer.  It  is  regarded  as 
safe  to  wait  until  the  patient  has  begun  to  improve  and  has  had  normal 
temperature  and  normal  blood  count  for  several  weeks.  Above  all,  the 
period  of  progressive  absorption  and  depression  must  be  over  and  no 
extragenital  complications  must  be  in  the  process  of  development.  The 
damaging  effect  of  the  gonococcus  determines  the  fact  that  most  of 
these  patients  finally  come  to  operation. 

Gonococcal  Chronic  Infection  of  the  Tubes  and  Ovaries. — The  chief 
prophylaxis  is  against  reinfection  by  the  husband  or  lover,  because  in 
many  of  these  patients  as  soon  as  the  subjective  symptoms  subside 
sexual  activity  is  resumed.  Another  preventive  measure  is  to  put  the 
patient  to  bed  at  the  slightest  sign  of  relapse  as  shown  by  temperature, 
blood  count,  pain  or  discharge. 

Brevity  requires  reference  to  Chapter  IX  on  General  Principles  of 
Treatment  for  description  of  management. 

Curative  Treatment. — After  from  two  to  four  weeks,  with  the  general 
condition  improved,  the  fever  absent,  leukocytosis  normal,  pulse  normal 
and  patient  able  to  move  are  the  factors  in  the  treatment  change. 

The  physical  measures  may  be  of  very  great  service.  jNIassage  is  a 
means  of  passive  exercise,  but  it  should  not  be  done  over  the  abdomen 
at  all  and  the  masseuse  must  be  skilled  and  obedient  to  orders  of  the 
physician.  The  hydrotherapy  is  the  various  forms  of  baths.  The 
sitting  bath  and  the  general  body  bath  are  both  good  and  if  the  reaction 


590  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

to  the  ^•igo^  of  the  bath  and  to  the  massaije  which  is  part  of  it  the 
Turkish  bath  is  excellent.  The  douches  are  continued  as  before  but  less 
frequently,  while  the  most  important  element  is  concerned  in  the  heat 
and  duration  rather  than  the  medication  in  the  fluid. 

The  medicinal  means  are  systemic  and  local  in  their  uses.  The 
systemic  application  is  sup])ort  of  the  patient  durinii;  the  a})proach  of 
the  chronic  period,  llematinics,  di^estants  and  laxatives  usually'  fulfil 
the  chief  indications.  Serumtherapy  has  already  been  briefly  discussed 
in  the  paraij;raph  on  the  acute  lesions.  As  a  rule  the  bacterins  are  of 
greatest  value  in  the  chronic  period.  Local  administration  is  by  douche 
or  tampon.  The  douche  is  given  in  the  standard  manner  described  under 
vaginitis,  with  the  same  general  formulie  and  two  or  three  times  daily 
instead  of  the  more  frequent  inter\'al.  Rest  in  bed  should  follow  such 
douching  when  possible.  A  cleansing  douche  is  advisable  before  the 
insertion  of  a  tampon  and  after  its  removal  so  as  to  cleanse  the  vagina 
of  discharge  from  the  disease  and  reaction  from  the  tampon.  The 
tampon  should  not  be  too  large,  must  be  carefully  placed  hi  the  fornices 
surrounding  the  cervix.  The  basis  of  the  medication  is  glycerin  with 
ichthyol,  guaiacol  and  the  like  in  from  10  to  25  per  cent,  strength. 
They  are  left  in  for  about  twelve  hours  or  overnight  and  a  dressing  is 
worn  to  receive  the  vaginal  discharge. 

The  surgical  measures  are  nonoperative  and  operative. 

The  nonoperative  means  are  chiefly  the  various  dressings  for  pus 
and  discharge,  catheterization  always  with  great  caution  for  retention 
of  urine  and  the  like.  These  have  been  included  in  previous  paragraphs. 

Ajtcrtrcatment  of  Nonoperaihe  Method. — Gradual  restoration  of  bodily 
function  is  the  immediate  aftertreatment  with  the  aim  of  having  diges- 
tion painless,  menstruation  normal  and  fecundity  possible  or  probable. 
In  not  a  small  number  of  these  cases  well  treated,  pregnancy  and  mater- 
nity occur.  The  remote  aftercare  is  watchfulness  in  every  way  during 
pregnancy  and  puerperiimi.  As  a  rule  the  slightest  onset  of  sjinptoms 
means  a  new  complication. 

Cvre. — In  the  pathological  sense  restoration  is  not  possible  through 
the  delicacy  and  complexity  of  the  parts  and  the  penetrating  destruc- 
tiveness  of  the  organism .  Symptomatic  cure  is,  however,  not  uncommon 
and  the  highest  degree  of  it  adds  physiological  restoration  so  that 
pregnancy  may  occur.  The  absence  of  gonococci  is  the  bacteriologic 
aim.  In  general,  massive  tubes  may  decrease  and  soften,  tender  infected 
ovaries  recover  and  a  fixed  congested  uterus  become  more  mobile. 

The  established  methods  of  operative  treatment  are  two :  palliative  or 
expectant  and  surgical  or  operative.  Palliation  should  always  be  tried 
carefully  as  already  detailed  in  the  preceding  paragraphs  and  operation 
must  be  deferred  until  expectant  means  have  failed  or  until  special 
indications  arise.  It  is  recognized  that  in  the  acute  period  operation 
is  avoided  except  in  rare  instances.  The  expectant  method  and  non- 
operative  means  are  practically  identical. 

The  operative  measures  are  conservative  or  radical,  in  which  the 
former  aims  to  remove  as  little  as  possible  and  the  latter  to  ablate  the 


GONOCOCCAL  INFECTION  OF  TUBES  AND  OVARIES        591 

organs.  In  the  selection  of  the  (;ase  and  election  of  tiie  time  for  opera- 
tion final  judgment  is  exceedingly  difficult  and  even  after  due  care  may 
be  frequently  wrong.  In  general  the  following  factors  obtain.  Persist- 
ing constitutional  symptoms  marking  progress  of  the  disease  with 
relapses,  pain  proceeding  from  chronic  congestion  of  displacement, 
menstruation  and  adhesions  and  excited  by  walking,  working,  urinating, 
defecating  or  cohabiting,  depressed  health  from  absorption,  intestinal 
disturbance,  constipation,  or  the  nervous  and  physical  strain,  dysmen- 
orrhea and  fresh  outbreaks  of  acute  suffering  are  all  important  factors. 
In  short,  the  patient  must  be  losing  ground  and  require  relief  by  either 
conservative  operation  with  preservation  of  all  possible  organs  or  radical 
operation  with  the  loss  of  all.  Like  the  expectant  or  palliative  method 
conservative  operations  should  be  attempted.  It  is  easy  to  remove 
organs  which  cannot  be  replaced  and  in  a  certain  sense  it  requires  more 
judgment  to  know  when  not  to  operate  than  it  requires  skill  to  operate. 
Secondary  operations  may  be  done  and  their  radical  degree  deter- 
mined by  the  outcome  of  the  conservative  steps. 

Other  elements  in  the  decision  are  sexual  and  social.  The  sexual 
factors  are  age,  with  its  influence  on  the  character  and  effects  of  men- 
strual life,  the  approach  of  normal  menopause  as  compared  with 
artificial  menopause,  the  number  of  children  living,  the  intensity  of 
maternal  instinct  in  unrealized  maternity  and  nervous  influences  and 
stability. 

The  ovary  more  markedly  than  the  testicle  has  a  profound  influence 
on  the  physical  economy.  It  is  the  essential  and  distinguishing  sex 
organ.  The  female  is  less  stable  physically  and  nervously  than  the 
male  and  mental  impressions  are  stronger.  Either  testis  or  ovary  may 
be  larger  than  the  average  and  yet  not  be  diseased.  The  presence  of 
the  ovary  determines  menstruation  primarily  and  in  ovulation  settles 
impregnation.  The  influence  of  inflammation  on  the  organ  cannot  be 
measm'ed  with  the  naked  eye  in  many  cases  without  obvious  abscess.. 
The  results  of  removal  of  the  ovaries  are  mild,  severe  or  extreme.  In 
the  mild  cases  there  is  little  or  no  disturbance,  but  in  the  severer  and 
average  cases  the  disturbances  are  numerous  and  common.  Extreme 
examples  go  on  to  insanity.  The  various  subjective  sjTnptoms  are  those 
of  the  forced  menopause,  the  failure  of  sexuality  and  untimely  sexual  old 
age.  The  objective  signs  are  hypertrophy  of  the  other  ovary  where  one 
has  been  spared  and  often  atrophy  of  the  uterus  in  marked  degree  and 
of  the  vulva  and  vagina  in  less  degree  when  both  have  been  taken  away. 
The  muscle  substance  of  the  uterus  suffers  more  early  and  severely, 
then  the  mucosa.    The  externalia  follow  in  due  time  and  course. 

The  social  elements  are  less  important.  The  leisure  class  may  receive 
attention  for  symptoms  following  a  conservative  operation,  whereas 
the  working  class  must  have  prompt  results  and  cannot  be  handicapped 
by  even  moderate  invalidism. 

In  the  election  of  time  of  operation  the  condition  of  the  lesion  and  of 
the  functions  rules.  As  to  the  functions  the  interval  between  menstrua- 
tions is  usually  the  best  because  there  is  less  nervous  disturbance,  con- 


592  aOXOCOCCAL  ISFECTIO.X  IX  THE  FEMALE 

^estion,  bleedins  and  tendency  to  infection  and  absorption.  As  to  the 
lesion,  cessation  of  active  symptoms  is  essential,  notably  temperature, 
blood  count  and  active  pus  absorption.  Finally  the  question  rests  on 
the  skill  and  the  knowledge  of  the  operator  to  judtje  the  pathological 
condition  in  situ  and  to  foresee  the  physiological  outcome  and  perceive 
the  needs  of  the  ])atient. 

Prdiininarii  Curettage. — After  the  technic  described  under  the  treat- 
ment of  endometritis  on  page  5C4,  a  curettement  of  the  womb  should 
be  done  followed  by  a])plication  of  an  antiseptic,  preferably  tincture  of 
iodin,  as  a  ])reliniinary  to  any  operation  on  the  tubes  and  ovaries. 
Its  acce])te(l  advantages  for  abdominal  o])erations  arc  that  the  iodin 
sterilizes  and  stimulates  the  endometrimn  after  the  curette  has  removed 
the  exuberant  diseased  mucosa.  By  attacking  the  infection  in  the 
uterus  it  remo\'es  one  of  the  chief  dangers  of  the  pelvic  peritoneum  when 
the  corpus  is  amputated  from  the  cervix  and  for  cervical  operations  it 
Hmits  discharge  from  above  during  the  period  of  repair. 

Conservative  Surgical  Treatment  of  the  Uterus  and  .inne.va. — Preser- 
vation in  operation  includes  the  uterus  and  one  tube  and  ovary  usually 
on  the  same  side.  The  anatomical  order  would  be  this,  but  the  uterus 
is  spared  in  many  operations  so  that  the  order  of  discussion  will  be 
tubes,  ovaries  and  uterus. 

Conservative  Salpingectomy. — Operation  on  the  oviduct  with  as  little 
damage  as  possible  is  most  important  and  the  subject  is  only  gonococcal 
infection.  In  the  selection  of  case  (1)  one  tube  may  be  normal  and  the 
other  diseased  and  both  o\aries  normal.  This  is  the  ideal  case  for  -uU 
conservation  of  the  opposite  tube.  (2)  A  more  rare  condition  is  a 
sterile  hydrosalpinx,  occurring  after  the  pus  has  been  absorbed,  leaving 
the  sermn  behind.  Such  tubes  in  either  class  must  be  reasonably  free 
of  adhesions  and  the  contained  pus  sterile.  A  difficulty  in  these  cases 
is  that  like  the  endometrium  the  lining  of  the  uterine  attachment  of  the 
tube  may  be  the  focus  of  infection  and  lead  to  relapses  if  not  removed. 

The  instriunents  and  supplies  are  assorted  knives,  scissors,  long 
forceps,  skin  and  parietal  retractors,  broad  ligament  clamps,  hemostats, 
ligature  carriers,  needles  for  peritoneum  and  skin,  needle-holders, 
abmidant  suture  material,  adhesive  plaster,  dressings,  binder,  etc. 
The  preparation  of  patient,  field,  surgeon  and  every  attendant  may 
be  any  of  the  approved  and  accepted  methods.  The  author  favors 
tincture  of  iodin  for  the  skin  of  the  patient  and  the  EUice  McDonald^ 
method  for  the  hands.  The  anesthetic  is  general  and  preferably  ether 
unless  contraindications  exist.  The  posture  is  dorsal,  changed  later  to 
the  full  or  exaggerated  Trendelenburg.  The  incision  is  median  in  all 
cases  of  doubt  or  slightly  lateral  over  the  afi'ected  side  in  cases  of  exact 
diagnosis.  The  Pfannenstiel  incision  is  praised  by  Child^  and  many 
other  writers. 

The  superficial  field  contains  the  skin,  fascia,  muscle  and  peritoneum 

'  Surg.,  Gynec.  and  Obst.,  July,  1914,  pp.  82  to  86.  Also  McMullen:  Ibid.,  July,  1915, 
pp.  87  to  88;  Albany  Annals,  January,  1917. 

-  Jour.  Am.  Med.  Assn.,  January  13,  1912,  Iviii,  91  to  94. 


GONOCOCCAL  INFECTION  OF  TUIiFS  AND  OVA  HIES         W.)'.\ 

of  the  abdominal  wall,  layer  by  layer.  Its  landmarks  an;  the;  symphysis 
pubis  below  and  the  umbilieus  above.  The  dec;})  fifsld  is  thf;  p(;lvis 
containing  the  uterus  and  annexa  and  must  be  fully  exposed  by  wallin'.f 
off  with  pads  in  all  direetions.  In  it  the  landmark  is  always  the  uterus 
whose  adhesions  must  be  gently  broken  down,  followed  by  those  of  the 
affected  broad  ligament  as  a  whole.  Without  eompl(;te  freerlom  the 
plastic  work  will  fail.  The  lateral  edge  of  the  broad  ligament  very  close 
to  the  tube  is  tied  to  catch  the  offsets  from  the  ovarian  artery  to  the 
infundibulum.  Between  the  ovary  and  the  tube  is  a  group  of  small 
vessels  which  may  be  individually  tied.  It  is  perhaps  better  to  cut  the 
tube  free  from  the  upper  edge  of  the  broad  ligament,  tying  these  vessels 
in  progress  up  to  the  tubal  insertion  into  the  uterus.  At  this  point 
are  more  vessels  secured  by  a  stitch  through  the  muscle  substance  of 
the  uterus  close  to  the  tube.  A  V-shaped  segment  of  the  myometrium 
is  removed  with  the  tube,  including  its  uterine  insertion,  and  the  wound 
is  at  once  repaired. 

The  foregoing  steps  include  removal  of  the  destroyed  tube  and  the 
following  steps  aim  to  restore  as  far  as  possible  the  anatomical  relations 
within  the  pelvis.  They  are  strongly  recommended  by  Norris.^  The 
round  ligament  folded  upon  itself  is  sewn  to  the  cornu  uteri  as  a  means 
of  support.  Then  the  raw  edge  of  the  broad  ligament,  with  all  bleeding 
stopped,  is  sewn  to  the  round  ligament  for  support  of  the  ovary  directly 
and  the  uterus  indirectly.  It  is  displacement  of  the  ovary  downward 
into  the  recto-uterine  pouch  after  these  operations  which  is  responsible 
for  adhesions,  ovarian  dysmenorrhea  and  dyspareunia  with  other 
symptoms.  Peritoneal  covering  may  be  borrowed  from  the  peritoneal 
ligaments  of  the  bladder  if  desired.  In  each  step  leakage  of  tubal  con- 
tents is  received  on  gauze  and  mopped  away  from  the  free  serous  surface. 
The  uterine  attachment  of  the  tube  may  be  gently  cauterized  in  its 
depth  before  the  ^^-shaped  wound  is  repaired.  Careful  toilet  of  every 
pocket  and  fold  of  the  deep  field  and  removal  of  all  pads  prepare  the 
patient  for  abdominal  suture.  In  a  good  case  uterus,  ovary  and  broad 
ligament  are  in  good  relation  without  undue  tension  which  would 
break  down  the  plastic  work.  In  the  dorsal  posture,  with  the  wound 
protected  by  fresh  towels,  layer  sutures  are  passed,  k.  firm  dressing 
is  applied  to  the  wound  and  carefully  secured  with  adhesive  plaster, 
extending  from  loin  to  loin,  beginning  above  and  ending  below  the 
dressing,  making  firm  support  duly  reinforced  by  a  good  many  tail 
binders.  The  patient  is  returned  to  bed  with  a  special  nurse  and  careful 
directions  as  to  signs  of  postoperative  hemorrhage  or  infection. 

Aftertreatment. — ^The  dressings  are  inspected  doT\m  to  the  skin  on  the 
fourth  or  fifth  day  of  une\'entful  cases  and  the  sutm^es  are  remo\'ed  in 
about  a  week.  Otherwise  each  case  is  a  law  unto  itself  in  special  indi- 
cations. With  primary  union  the  patient  is  supported  in  bed  about  the 
tenth  day  and  is  out  of  bed  about  the  fourteenth  day.  The  immediate 
aftertreatment  is  that  just  stated,  while  remote  aftercare  is  comprised 

'  Loc.  cit, 
38 


594  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

in  attention  to  the  uterine  and  other  infections  from  Avhich  tlie  tubal 
disease  proceeded,  all  according  to  indications. 

Cautions. — Infection  of  the  general  peritoneal  cavity  is  the  chief 
danger  but  \'ery  rarely  occiu's  in  pro]:)er  selection  of  case  and  manage- 
ment of  the  deep  field.  Xorris,  as  cited,  points  out  the  danger  of  too 
many  deep  ligatures  about  the  ovarian  vessels  which  may  reduce  the 
blood  su])ply  and  cause  ovarian  malnutrition.  Tension  on  suture  lines 
has  already  been  discussed,  likewise  failure  to  restore  ovarian  relations. 
Equally  imj)ortant  is  failure  to  supi)ort  the  uterus  so  that  it  does  not 
wabble  about  between  bladtler  and  rectmii.  Raw  spots  uncovered  by 
peritoneum  lead  to  adhesions.  Neglect  of  these  cautions  promotes 
])artial  or  complete  failure. 

]{(i(lir(il  Sdlpingccto))!!/. — For  this  operation  the  selection  of  case 
implies  bilateral  tubal  and  o\'arian  gonococcal  infection,  which  is 
destructive  through  complexity  of  the  folds  of  the  mucosa  and  through 
nonresistance  to  the  gonococcus.  As  a  rule  the  uterus  must  be  sacri- 
ficed in  such  cases,  because  it  is  otherwise  left  entirely  unsupported 
and  becomes  a  source  of  vesical,  rectal,  digestive,  nervous  and  other 
symptoms.  If  the  tubes  are  left  the  technic  is  much  the  same  as  that 
just  described,  except  that  all  conservative  steps  must  be  omitted.  The 
caution  is  to  remove  the  uterine  implantations  of  the  tubes  lest  the 
disease  at  these  points  cause  relapses  which  as  reported  by  Norris  in 
his  classic  work,  as  cited,  and  by  others,  may  take  the  form  of  cornual 
abscess  or  intramural  tubal  pregnancy. 

Partial  Oophorectomy. — In  leaving  part  of  the  ovary  behind,  the 
selection  of  case  defines  focal  and  not  general  involvement,  which  means 
that  the  abscess  is  superficial  and  localized,  lea\'ing  the  balance  of  the 
organ  normal.  As  in  the  gonococcal  tubal  disease  so  in  gonococcal 
ovarian  disease  the  prospects  of  conservation  are  relatively  poor.  The 
best  cases  for  this  form  of  plastic  surgery  are  the  least  common  in 
gonococcal  infection — single  cysts.  The  technical  details  throughout 
duplicate  those  just  described  for  conservative  tubal  surgery.  The 
ovary  is  incised  as  required,  the  disease  zones  removed  and  the 
remainder  of  the  gland  carefully  sutured  so  as  to  coapt  the  tunica 
albuginea  evenly  and  fully,  without  tension,  compression,  deformity 
or  strangulation  of  blood  supply.  All  the  clinical  features  are  the  same 
as  those  shown  for  conservation  of  the  tubes  with  the  following  cautions 
against  infection  through  the  blood  clots  and  defective  asepsis,  against 
oophoritis  through  rough  handling  or  other  traumatism;  against 
adhesions  through  uncovered  surfaces;  against  prolapse  through  faulty 
position  of  the  ovary  or  uterus  and  their  tug  on  the  broad  ligament; 
and  against  cystic  changes  through  poor  circulation. 

The  results  are  occasionally  pregnancy  when  the  remainder  of  the 
ovary  is  healthy  and  contains  the  ovulating  segment  of  the  organ. 
Unfortunately  this  is  the  part  chiefly  sacrificed  in  resection  operations. 
It  is  known  experunentally  that  animals  will  procreate  with  only  a 
small  portion  of  ovary.  A  temporary  difficulty  is  enlargement  and 
inflammation  which  subside  more  or  less  completely  after  a  few  weeks. 


GONOCOCCAL  INFECTION  OF  TUJiFS  AND  OVARIES         595 

Both  in  the  inflammation  and  its  subsidcn(;c  th(;  ovary  flnpliratfs  the 
performance  of  the  testis  in  Hke  circumstances.  Prolaj^se  heliiiKi  the 
uterus  leading  to  adhesions,  congestion  and  inflammation  is  another 
disadvantage  resting  on  loss  of  normal  support  of  the  organ.  Second- 
ary operations  after  attempted  conservation  are  not  uncommr^n, 
especially  in  gonococcal  cases,  and  are  the  chief  disadvantage  of  post- 
poned radical  measures.       ^ 

Conservative  Uterine  Surgery. — The  health  and  function  of  the  uterus 
are  influenced  by  the  ovaries  and  it  becomes  practically  a  useless  organ 
without  them  and  very  soon  atrophies  through  suspension  oi  menstrual 
activity.  Removal  of  both  broad  ligaments  in  part  along  with  both 
tubes  and  ovaries  essentially  interferes  with  the  support  and  position 
of  the  uterus  which  becomes  displaced  and  often  adherent  and  by  its 
physical  presence  and  weight  excites  vesical  and  rectal  s,>Tnptoms 
and  by  its  abnormal  condition  and  traction  brings  on  much  pain  and 
invalidism.  Moreover  the  plastic  repair  of  the  upper  pelvic  floor 
between  the  rectum  and  the  bladder  is  much  more  successful  without 
the  uterus  than  with  it.  The  consensus  of  opinion  is  therefore  to  remove 
the  uterus  when  bo-th  tubes  and  ovaries  must  be  sacrificed. 

Results  and  Comments  of  Conservative  Measures. — Results. — Of  chief 
importance  is  mortality  which  is  certainly  lessened  to  a  material  degree. 
The  morbidity  is  likewise  decreased  by  giving  a  better  selection  of 
operation  and  election  of  time  than  if  early  interference  is  followed. 
Cures  are  regarded  as  representing  about  75  per  cent,  of  the  cases, 
improvements  nearly  20  per  cent.,  and  failures  about  5  per  cent., 
which  is  as  good  a  record  as  could  be  reasonably  expected.  General 
health  is  more  or  less  fully  restored  in  the  cures  and  benefited  in  the 
improvements.  Menstruation  may  be  ultimately  not  afi^ected  or  if  dis- 
turbed it  is  chiefly  delayed  or  irregular.  Normal  pregnancy  is  always 
physically  possible  in  the  cures  although  often  not  probable,  but  inas- 
much as  it  is  without  exception  mentally  expected  and  hoped  for,  the 
courage  of  the  patient  remains  good.  Tubal  pregnancy  is  by  no  means 
uncommon.  In  fact,  it  is  admitted  that  one  of  the  most  potent  causes  of 
this  abnormality  is  inflammatory  change  in  the  lining  and  form  of  the 
tubes.  Revision  of  operation  or  secondary  interference  at  a  later  date 
is  due  to  incidence  of  the  disease  upon  the  previously  normal  opposite 
tube  or  its  progress  in  a  macroscopically  apparently  normal  tube.  The 
percentage  of  these  cases  is  about  6  per  cent,  which  nearly  corresponds 
with  the  approximate  5  per  cent,  of  failures  just  stated. 

Comments. — A  review  of  the  surger}-  of  the  uterus  and  annexa  in 
gonococcal  infection  is  divisible  into  preliminary  treatment,  the  choice 
of  operation  as  to  successes  and  failures  and  the  aftertreatment. 

Judicious  preliminary  treatment  is  always  worth  while.  It  often 
avoids  operation  and  always  oft'ers  improved  conditions  at  the  opera- 
tions and  greater  independence  in  the  election  of  tune  for  interference. 

In  the  choice  of  operation  and  time  of  operation  decision  is  made 
between  immediate  interference  and  delayed  invasion  as  to  time  and 
conservative  and  radical  measures  as  to  method.    Another  view-point 


590  GOXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

is  that  of  the  unfavorable  and  the  favorable  procedures  both  in  time  and 
technic.  The  basis  of  each  has  already  been  named  in  discussing  the 
various  methods. 

A  preliminary  curetting  must  proceed  any  of  the  operations. 

I.  Among  the  unfavorable  decisions  are  to  be  named  the  following: 

1.  Immediate  evacuation  of  pus  except  when  the  ])atient  is  doing 
badly  and  when  the  i)erit()neal  cavity  is  natin*ally  walled  oil". 

2.  Plastic  repair  of  gonococcal  tubes  because  the  remnants  are  of 
little  value  and  often  highly  pathologic  microscopically. 

3.  Conservation  of  grossly  diseased  gonococcal  tubes  is  a  mistake 
because  it  leaves  a  potent  focus  untou(hed  and  often  causes  extension 
and  secondary  operation. 

4.  Radical  measures  are  less  favored  than  conservative. 

11.  Among  the  favorable  decisions  are  to  be  classed  the  following: 

1.  Conservation  of  a  normal  annexum  when  its  fellow  is  diseased. 

2.  Conservation  of  one  or  both  ovaries  if  nutrition  in  the  circulation 
and  normal  position  by  i)lastic  rei)aii"  are  obtained.  Ovulation  and 
menstruation  continue. 

3.  Conservation  of  one  or  both  ovaries  in  hysterectomy.  0\'ulation 
continues  although  menstruation  is  abolished. 

4.  Partial  oophorectomy,  with  restoration  of  the  coats  by  suture, 
preservation  of  circulation  by  judicious  ligatiu-e  and  of  ovulation  by 
sparing  the  follicular  zone. 

5.  Total  hysterectomy  if  both  appendages  must  be  sacrificed.  Sub- 
total hysterectomy  in  youth  with  a  portion  of  the  uterus  and  ovulation 
and  menstruation  essential. 

In  choice  of  time  of  operation  the  immediate  evacuation  of  pus  has 
already  been  detailed  in  the  foregoing  paragraphs.  The  period  of  sub- 
sidence of  SATiiptoms  or  the  chronic  stage  is  almost  always  the  best  for 
operation. 

The  aftertreatment.like  the  preliminary  treatment,  is  very  unportant 
and  provides  for  control  of  the  minor  postoperative  ills  and  the  restora- 
tion of  bodily  health  and  the  equalization  of  sexual  function  so  far  as 
jiossible. 

Radical  Pelvic  Surgery. — This  term  usually  includes  removal  of  all 
the  internal  sexual  organs  in  woman.  It  therefore  means  sacrifice  of 
the  uterus  as  a  whole  or  down  to  the  vaginal  portion  of  the  neck  com- 
bined with  both  tubes  and  ovaries.  The  majority  of  operators  are  apt 
to  leave  the  stump  of  the  neck  to  simplify  and  shorten  the  procedure. 
The  technic  is  the  same  as  that  given  for  hysterectomy  without  or 
with  both  appendages  under  metritis.  With  proper  selection  of  case 
and  well-balanced  preliminary  treatment  radical  methods  are  less  and 
less  common  in  gonococcal  infections. 


CHAPTER   XI. 

COMPLICATIONS,  SEQUELS  AND  RARE  EORMS  OF  (GONO- 
COCCAL INFECTION  IN  THE  FEMALE. 

AGE  AS  A  FACTOR  OF  IMPORTANCE. 

General  Significance. — In  the  male  the  chief  and  primary  lesion  is 
gonococcal  urethritis,  about  which  are  grouped  the  minor  and  major 
complications  as  they  occur  in  the  urinogenital  system  and  the  body  at 
large,  respective]}^  constituting  the  urinogenital  and  the  extra-urino- 
genital  groups.  In  the  female  the  same  rule  could  be  followed,  and 
formerly  was  adopted  by  accepting  vulvovaginitis,  without  or  with 
urethritis,  as  the  primary  inoculation  and  all  other  lesions  as  compli- 
cations or  sequels  thereof.  The  modern  tendency,  however,  is  to 
regard  the  sexual  mucosa  as  a  whole  from  vulva  to  peritoneum,  and  the 
invasion  by  the  gonococcus  of  any  part  thereof  not  as  a  complication 
but  as  an  involvement  in  continuity  and  contiguity  in  the  ordinary 
progress  of  the  disease,  according  to  severity. 

This  plan  makes  uncomplicated  gonococcal  disease  in  the  female  a 
truly  sexual  disease  and  begins  to  add  complications  only  when  the 
urinary  system  becomes  involved  in  bladder,  ureters  and  kidneys,  and 
when  the  whole  body  is  occasionally  involved  in  any  of  its  systems. 
This  view  could  be  and  in  the  author's  opinion  should  be  accepted  for 
the  male  also.  It  is  readily  foreseen  that  ere  long  this  will  be  the 
pathogenetic  standard  and  will  constitute  scientific  progress.  Inasmuch, 
however,  as  the  older  distinction  as  to  the  male  is  still  found  in  widest 
acceptance  it  has  been  adopted  in  this  work. 

The  rare  forms  or  manifestations  of  gonococcal  disease  may  belong 
to  the  genital  or  extragenital  groups  and  the  most  important  include 
the  following:  Among  the  genital  lesions  are  chiefly  hydrops  tubse 
profluens,  torsion  of  gonococcal  uterine  annexa,  associated  infections 
and  gonococcal  tubal  pregnancy. 

Among  the  extragenital  lesions  are  chiefly  intraperitoneal  rupture 
of  gonococcal  foci  and  gonococcal  general  peritonitis. 

I.  EXTRAGENITAL  OR  SYSTEMIC  COMPLICATIONS. 

Classification. — There  are  in  the  female,  as  in  the  male,  two  groups, 
which  are  the  urinary  and  the  systemic. 

A.    Urinary  Group. 

Clinical  Features. — There  is  no  essential  or  material  difference  be- 
tween the  sexes  in  complications  of  the  urinary  organs — bladder, 
ureters  and  kidncA's. 


59S    RARE  FORMS  OF  GOXOCnCCAL  IXFECTfOX  IX   THE  FEMALE 

Gonococcal  Cystitis,  Ureteritis  ;iiul  Pyelitis,  in  their  clinical  features, 
arc  in  cNcry  way  the  clui)licates  of  those  found  in  the  male,  and  the 
reader  will  note  the  descriptions  thereof  in  the  earlier  ])art  of  this  work. 


Fig.  128. — A,  A,  the  ducts  leading  from 
Skene's  glands  swollen  and  everted.  The 
black  dots  represent  the  openings. 
(Dudley.') 


Fici.  129. — Urethral  caruncle  at  one 
side  of  the  meatus,  simulating  in  appear- 
ance the  swollen  and  everted  Skene's 
duct.  Obser%'^e  the  absence  of  the  opening 
of  a  duct.     (Dudley.) 


\ 

\.  .: 

A 

^ 

^ 

^ 

1 

i      M 
A 

p 

I'k..  1.30. — Expres.sion  of  pus  from  the 
ducts  of  Skene's  glands.  With  two  fingers 
within  the  vagina  to  support  the  urethra 
from  slipping  to  either  side  a  sterilized 
hair-pin  may  be  passed  into  the  urethra, 
turned  .slightly  sidewdse  over  the  glands 
and  drawn  forward,  pressing  out  their 
individual  contents  exactly  like  a  come- 
done.  This  manipulation  will  succeed 
often  when  simple  pressure  fails. 
(Dudley.) 


Fig.  131. — A  large  hypodermic  syringe 
needle  with  blunt  point  and  rubber  bulb 
attached.  This  is  intended  as  a  pipette, 
by  means  of  which  may  be  injected  into 
Skene's  ducts  medicinal  substances  for 
treatment  of  infection.      (Dudley.) 


Principles  and  Practice  of  Gynecologj\  6th  ed.,  p.  329. 


GONOCOCCAL  CONDYLOMATA  ACUMINATA  599 

B.    Systemic  Cihoup. 

Clinical  Relations. — As  in  the  male,  the  process  of  a})sorptioii  may 
involve  any  system  of  the  body  in  complications,  which  then  are  desig- 
nated in  accordance  with  the  system  attacked.  ^J'he  relative  freqiuTicy, 
importance  and  results  in  the  female  are  in  no  real  detail  otherwise 
than  in  the  male. 

The  reader  will  find  the  various  complications  as  they  arise  in  the 
male  fully  discussed  in  the  order  of  systems  of  the  })ody. 

II.    GENITAL  OR  LOCAL  COMPLICATIONS. 

Classification. — Tlie  more  usual  sexual  complications  are  urethral, 
pudendal  and  uterine.  The  urethral  lesion  of  importance,  thf)Uffh  not 
frequent  in  the  woman,  is  stricture,  and  those  of  the  pudendum  are 
condylomata  acuminata,  pruritus  vulvae  and  vestibular  adenitis. 
Abscess  of  the  uterine  muscle  is  the  one  tiue  uterine  complication. 

STRICTURE  OF  THE  URETHRA. 

Clinical  Features. — This  lesion  in  woman  is  much  less  common  than 
in  man,  through  the  nature  of  the  urethra,  w^hich  is  the  most  dilatable 
part  of  the  canal.  It  may,  however,  as  in  the  male,  occur  at  any  point 
of  the  passage,  and  is  therefore  meatal  or  intraurethral  in  site.  Its 
form  is  very  commonly  annular,  but  it  may  have  any  of  the  irregulari- 
ties seen  in  stricture  of  the  other  sex. 

Symptoms. — The  symptoms  subjectively  duplicate  those  in  man  and 
are  chiefly,  frequency,  urgency,  dysuria,  pollakiuria  and  tenesmus. 
Total  obstruction  of  the  canal  is  rarely  seen.  The  objective  symptoms 
make  the  diagnosis.  Inspection  will  reveal  the  deformity  if  meatal 
and  palpation  with  the  finger  or  with  instruments  will  detect  the  nodule 
in  the  canal  from  the  vestibule  and  vagina. 

Treatment. — Stricture  of  the  female  urethra,  as  in  the  male,  may  be 
dilated  or  divulsed.  The  last  measure  is  not  advisable.  The  majority 
of  strictures  respond  well  to  gradual  dilatation  and  only  a  few  must  be 
incised.  All  the  preliminary  diagnosis  and  treatment  and  the  after- 
treatment  prescribed  for  the  male  in  Chapter  ^TI  must  be  followed 
in  the  female. 

GONOCOCCAL  CONDYLOMATA  ACUMINATA. 

Significaiice. — Significance  establishes  that  this  lesion  is  a  common 
accompaniment  of  clu-onic  mixed  infection  in  uncleanly  subjects  and 
appears  in  the  folds  and  apposed  surfaces  of  the  external  genitals  and 
skin  much  like  verruca  in  other  parts  of  the  body. 

Varieties. — The  varieties  are  the  sessile,  having  a  broad  base,  and  the 
pedunculated,  having  a  more  or  less  narrowed  attachment. 

As  to  situation,  gonococcal  condylomata  acuminata  are  urethral. 


()()()    RARE  FORMS  OF  COXOCOCCAL  I.\FECTU).\    I X   THE  FEMALE 

anal,  irctal  ami  \ul\ar,  which  foiiipriso  the  most  comnioii  tlisti  il)utions, 
or  they  are  vaginal  and  cervical  as  rare  nianilestations. 

Etiology. — The  etiology  is  regularly  the  irritation  of  the  papillary 
layer  of  the  skin  on  tlie  outer  surface  and  of  the  modified  skin  on  the 
inner  surfaee  of  the  Aulva  anil  anns  by  the  gonococcus  and  allied 
organisms,  their  excoriating  exudate  and  its  retention  in  folds,  recesses 
and  ai)posed  jvirts. 


Fig.  132. — Author's  case  of  nongonococcal  condylunuita  acuminata.  The  patient 
was  a  woman  with  a  leucoirhea  examined  negatively  for  gonococci  seven  times.  The 
warts  developed  steadily  notwithstanding  antiseptic  douches  and  drying  powders.  A 
strange  coincidence  in  the  case  is  that  her  lover  also  had  warts  but  not  in  a  pronounced 
degree.  He  was  never  examined  by  the  author  because  he  refused  to  come,  so  that  the 
identity  of  the  infection  in  both  patients  was  never  estabhshed. 

For  the  pathology  the  reader  is  referred  to  this  subject  in  the  male 
on  ])age  20o. 

Symptoms. — The  symptoms  are  cosmetic,  ftmctional  and  exudative, 
subjective  and  objective,  local  and  .systemic.  The  .subjective  local 
.symptoms  are  annoyance  at  the  appearance  of  the  parts,  in  vulvar 
warts,  especially  if  the  warts  are  extensive,  and  fear  that  they  may  be 
serious  rather  than  simple.  The  functional  condition  is  more  or  less 
raarkefl  dyspareunia  and  hemorrhage  on  the  least  sexual  or  other 
contact.  The  discharge  is  irritating,  .sanious,  muco.serous  or  seropuru- 
lent,  and  highly  irritating  to  the  adjoining  skin,  where  eczema  is  often 


CONOCOCCAL  CONDYLOMATA    ACUMINATA 


601 


produced.  It  is  also  oflensive  in  odor  and  infectious  to  the  male  organ. 
The  objective  local  syin[)t()nis  are  the  warts  tliernselves,  which  may  he 
few  or  many,  discrete  or  confluent,  sessile  or  pedunculated,  slightly  or 
deeply  fissured,  and  in  situation  internal  or  external,  vulvar,  anal, 
vaginal  or  even  pudendal.  AH  these  regions  may  be  invaded  and  the 
entire  vulvar  cleft  filled.  Jileeding  and  tenderness  are  common  and 
discharge  as  just  described  is  the  rule,  especially  with  secondary  infec- 
tion. The  gonococcus  is  not  within  the  tissue  of  the  verruca,  but  in  the 
crevices  and  clefts  of  its  surface  and  in  the  skin  adjoining.  The  gono- 
coccus may  be  absent  and  its  place  taken  b>'  the  common  [)>-ogenic 


Fig.  133. — Author's  case  of  gonococcal  condylomata  acuminata.  The  lesions  were 
universally  around  the  anal  and  pudendal  regions  and  extended  into  the  vagina  but  not 
into  the  bowel.  They  were  removed  with  scissors,  curette  and  caustic  without  relapse 
after  nearly  two  years. 


organisms  of  the  skin.  The  author's  case  of  nongonococcal  condylo- 
mata acuminata  is  shown  in  Fig.  133.  At  least  eight  separate  exami- 
nations failed  to  detect  the  gonococcus  in  any  of  the  organs  and  any  of 
the  warts. 

The  vaginal  condylomata  have  much  the  same  etiology  and  path- 
ology as  the  vulvar  and  anal  forms,  but  their  occurrence  is  much  less 
frequent.  In  site  they  are  most  common  in  the  lower  segment  of  the 
vagina,  but  any  and  all  the  other  portions  may  be  involved.  Their 
form  is  that  of  the  typical  cock's-comb  venereal  wart,  with  possibly  a 
smaller  pedicle  and  a  flatter  body,  due  to  apposition  of  the  walls  of 
the  colpos.    The  subjective  sympton^s  are  a  mild  irritation  and  dis- 


G02     RARE  FORMS  OF  COXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

cliarge  and  a  certain  cosmetic  ett'ect.  Objecti\ely  their  condition  is 
characteristic  as  discussed  in  the  male,  and  if  the  (Haunosis  is  at  all 
doubtful,  microscopic  investigation  <if  one  of  the  smaller  lesions  will 
settle  it.  Their  treatment  re(|uires  the  same  measures  asci)sis,  dryness, 
caustics  and  remo\  al  with  knife  or  scissors.  Caution  as  to  contracture 
from  scars  of  the  larger  warts  is  essential.  The  aftertreatment  recjuires 
attention  to  the  cer\ical  and  vaginal  mucosa  to  cure  the  irritating- 
discharge,  which  is  usually  at  the  basis  of  these  lesions. 

Diagnosis. — Condyloma  acuminatum  is  readily  recognized  as  a 
chronic  lesion  asstx-iatcd  with  \agino\ulvar  ilischarge,  which  on  history 
is  usually  of  sexual  origin,  proceeding  from  infection  thus  acquired. 
Other  features  of  diagnosis  and  ditt'erential  diagnosis  arc  identical  with 
those  of  this  lesion  noted  in  the  male  on  page  204.  Conclusion  that  a 
case  is  nongonococcal  must  be  slowly  reached  after  a  number  of  search- 
ing analyses  of  the  case,  because  in  any  example  the  gonococcus  may 
have  disappeared.  In  the  author's  case,  shown  in  Fig.  133,  the  condj-- 
lomata  were  rapid  in  their  onset  and  disappeared  rather  quickly,  as 
stated  in  the  paragrapli  on  treatment.  At  least  eight  si)ecimens  negative 
for  the  gonococcus  were  secured,  and  most  important  the  woman  was 
having  intercourse  with  one  man  over  a  protracted  period  of  months 
without  his  having  acquired  gonococcal  infection.  The  warts  are  like 
a  cock's-comb,  white  or  reddish,  always  more  or  less  moist,  with  exu- 
date which  is  sticky  and  foul-smelling  and  often  hemorrhagic.  The 
bases  are  pedunculated  or  sessile. 

Treatment. — As  in  vulvitis,  cleanliness  and  dryness  are  the  prophy- 
laxis, Avhose  other  details  are  the  same  as  those  described  in  the  male 
on  page  205,  and  diiYer  only  according  to  the  anatomy.  Abortive  treat- 
ment is  impossible  except  that  the  removal  of  the  earliest  and  smallest 
growths  followed  by  added  attention  to  freedom  from  discharge  may 
stop  further  developments. 

Curative  Treatment. — The  indications,  management  and  physical 
measures  are  sufficiently  discussed  in  this  complication  in  the  male  and 
in  vulvitis.  The  electrotherapy  includes  the  .r-ray,  actual  cautery  and 
the  high-frequency  current  of  Oudin.  The  rc-ray  in  mild  potentiality 
may  prove  of  value  in  destroying  the  infection  and  inhibiting  the 
growths,  inasmuch  as  these  are  limited  to  the  normal  skin  of  the  outer 
surface  and  the  modified  skin  of  the  inner  surface  of  the  vulva.  It  is 
known  that  the  .r-ray  is  not  very  efficient  in  growths  of  the  mucosa. 
The  electrocautery  used  at  dull  redness  alone,  is  safe.  The  high- 
frequency  current  of  Oudin  is  applied  in  drying  strength  for  smaller 
growths  and  coagulating  strength  for  larger  warts,  as  described  in  the 
soap  test  in  the  general  subject  of  electrotherapeutics  on  page  499. 
It  is  rarely  necessary  to  reach  the  charring  strength  of  current. 

The  medicinal  measures  are  also  the  same  and  respect  the  chronic 
periods  of  the  disease  when  alone  these  lesions  appear.  Nothing  new 
may  be  added  except  the  method  of  Schein,^  consisting  of  causing 

'  Wien.  klin.  Wchnschr.,  xviii,  5. 


GONOCOCCAL  VESTIBULAR  ADEN  FT  IS  WA 

thrombosis  in  the  condylomata  by  spraying  on  ethyl  chloride.  '^J'his  is 
a  bloodless  means  of  shedding  the  warts  and  is  recommended  also  by 
Norris,^  who  adds  that  the  freezing  must  })e  e(jntinued  for  four  or  five 
minutes  for  each  growth  to  secure  efficiency. 

The  surgical  measures  are  nonoi)erative,  as  presented  in  tiiis  lesion 
in  the  male,  and  operative.  The  preparation  of  the  field  is  rather  long 
treatment  for  as  much  freedom  from  discharge  and  exudate  as  possible 
and  dryness  of  the  i)arts.  Only  extensive  cases  require  a  general  anes- 
thetic, whereas  cocain  solution  may  be  infiltrated  aroinid  and  into  the 
base  of  smaller  warts.  The  larger  growths  may  be  clipped  away  with 
the  scissors  or,  better,  with  the  knife  rather  deeply  and  widely  into  the 
base  away  from  the  pedicle.  The  gaping  wounds  are  stitched  with 
horse-hair,  fine  catgut  or  silk.  The  smaller  verruca  may  be  curetted 
away  with  the  sharp  intrauterine  curette  intersecting  the  base,  as  in  the 
author's  case  of  the  illustration,  Fig.  133.  Extensive  examples  of  the 
disease  require  several  sittings  in  order  to  avoid  opening  many  avenues 
of  infection.  Mild  caustics,  such  as  10  per  cent,  silver  nitrate,  are 
applied  to  all  raw  surfaces  for  antisepsis  and  hemostasis.  Local 
applications  of  caustics,  with  protection  of  the  annexa,  will  ablate  the 
smaller  outgrowths.  The  wounds  of  any  method  must  be  dressed  on 
surgical  principles. 

Aftertreatment. — Surgical  care  of  sutured  wounds  and  raw  spots  is 
the  immediate  aftertreatment  in  order  to  prevent  infection  and  ulcer- 
ation, which  may  be  extensive  and  partake  of  chancroidal  tendency. 
The  remote  aftertreatment  is  a  return  to  the  prophylactic  principles 
of  cleanliness  and  dryness  to  provide  against  relapse. 

Cure. — The  tendency  towards  warts  is  inherent  in  many  skins  under 
very  little  irritation.  These  patients  will  have  several  more  or  less 
troublesome  crops  until  the  gonococcal  and  allied  infections  of  the 
upper  genitals  are  relieved. 

GONOCOCCAL  PRURITUS  VULV^. 

Significance. — Pruritus  ani  et  vulvae  have  been  proved  by  Murray^ 
to  be  due  to  the  streptococcus.  Undoubtedly  the  gonococcus  is 
occasionally  a  factor. 

Clinical  Features. — Etiology,  pathology,  symptoms  and  diagnosis 
are  treated  of  in  works  on  gynecology. 

Treatment. — ^The  serum  method  described  by  IMiu-ray,  associated  with 
surgical  cleanliness  and  dryness,  is  the  one  scientific  procedure. 

GONOCOCCAL  VESTIBULAR  ADENITIS. 

Synonyms. — Synonj-ms,  chiefly  due  to  changes  in  anatomical  nomen- 
clature are  bartholinitis,  vulvovaginal  adenitis  or  vestibular  adenitis. 

1  Gonorrhea  in  W^omen,  1913,  p.  200. 

2  Jour.  Am.  Med.  Assn.,  December  9,  1911;  Tr.  Am.  Proctologic  See,  1913,  1914,  and 
1915. 


604    RARE  FORMS  OF  GOXOCOCCAL  IXFECTIOX  IN  THE  FEMALE 

The  terms  abscess  antl  cyst  may  also  be  applied  to  either  of  the  qualify- 
ing anatomical  terms.  The  duct  may  be  the  sole  and  chief  focus,  or 
both  duct  and  gland  are  diseased. 

Significance. — Significance  lies  in  the  freciuency  of  gonococcal  vesti- 
bular adenitis  associated  with  \ul\ovaginitis  arising  from  the  anatomy 
of  the  ducts  and  glands  which  are  the  homologues  of  Cowper's  glands 
and  from  the  location  of  the  duct,  which  is  bathed  by  the  male  emission 
and  thus  directly  infected  or  cotered  by  the  exudate  from  above  and 
thus  indirectly  infected.  Physiological  activity  during  coitus  probably 
oi)ens  the  tlucts  in  the  discharge  of  lubrication  an<l  thus  inx'ites  entrance 
of  the  organisms. 

Varieties. — The  varieties  are  acute  and  chronic,  with  occlusion  and 
without  occlusion  of  the  duct,  and  the  macroscopic  pathology  dupli- 
cates that  described  by  Cowper's  glands  and  the  essence  is  acute 
infection  with  occlusion  of  the  duct,  retention  of  pus  products, 
destruction  of  gland  substance  and  true  abscess  formation,  or  it  is  acute 
infection  without  occlusion  and  with  free  discharge  of  pus  products. 
Ketention  with  less  destruction  of  the  gland  produces  cysts. 

Etiology. — The  etiology  is  either  the  gonococcus  alone  or  with  its 
pyogenic  allies. 

Pathology. — Microscopic  pathology  differs  in  the  two  forms  as 
follows : 

In  vestibular  adenitis  withovt  occlusion  there  occur  the  infection  and 
common  changes  of  glandular  disease,  as  the  tem])orary  lesions,  com- 
prising hyperemia,  cellular  infiltration,  desquamation  and  substitution 
of  specialized  epithelium,  pus,  blood,  detritus  and  gonococci.  The 
permanent  lesions  in  mild  cases  are  few  or  none  to  interfere  with  the 
use  of  the  glands,  or  deep  destruction  will  lead  to  chronic  change  and 
thickening,  so  that  parts  or  the  whole  of  the  glands  cease  their  function 
and  become  sinuses,  with  persistent  or  relapsing  discharge. 

In  vestibular  adenitis  with  occlusion  a  true  abscess  forms  involving 
at  least  part  but  more  commonly  the  whole  gland,  so  that  temporary 
lesions  of  the  parenchyma  are  lacking  while  the  permanent  lesions  are 
marked  with  gonococcal  destruction  of  the  gland  by  inflammation, 
penetration,  desquamation  and  destruction  of  all  cellular  elements, 
with  substitution  of  a  typical  pyogenic  membrane  for  them.  Thus  the 
whole  gland  is  finally  destroyed.  The  associated  lesions  are  those  of 
gonococcal  disease  in  the  urethra,  vulva,  vagina  and  cervix,  from  which 
the  adenitis  directly  or  indirectly  originated.  These  may,  however, 
have  subsided  while  the  chronic  adenitis  persists.  The  complicating 
lesions  duplicate  those  w^hich  are  common  to  the  disease  in  the  female 
in  general  terms. 

Symptoms. — These  are  acute  and  chronic,  subjective  and  objective, 
local  and  systemic,  and  are  based  on  the  stage  of  the  infection  and  the 
absence  of  any  occlusion  of  the  duct.  Distinct  tendency  toward  chro- 
nicity  is  noted.  Activity  of  the  accompanying  urethritis,  vulvovaginitis 
and  other  gonococcal  lesions  may  modify  the  s^Tnptoms  of  the  adenitis, 
and  those  of  the  latter  may  persist  long  after  the  former  are  absent, 


GONOCOCCAL  VESTIBULAR  ADENITIS  (305 

or  may  arise  and  run  their  course  long  after  other  gonococcal  lesions 
have  disappeared.  These  may  be  the  idiopathic  cases  or  the  non- 
gonococcal cases  in  which  other  organisms  are  causative. 

Acute  vestibular  adenitis  varies  with  the  presence  or  absence  of 
occlusion  and  by  the  same  law  determines  the  chronic  forms:  that 
with  persistent  discharge  through  the  duct  of  a  diseased  gland  and 
that  with  sinus  and  fistuhe  from  a  ruptured  abscess. 

Acute  vestibular  adenitis  without  occlusion  has  the  following  sensory 
and  functional  disturbances  as  the  subjective  local  symptoms.  The 
usual  stages  of  the  disease  are  recognized  as  invasion  which  merges 
quickly  into  the  establishment  with  discomfort,  then  real  or  violent 
pain  and  tenderness  in  the  affected  gland  or  glands,  increased  by  motion 
—voluntary,  as  in  moving,  or  passive,  as  in  riding — and  decreased  h>y 
rest  or  separation  and  support  of  the  thighs.  Discharge  from  the  duct 
of  the  affected  gland  is  prominent  and  may  otherwise  come  from  gen- 
eral vulvovaginal  infection  associated  with  the  urethritis.  The  vulvo- 
vaginitis and  ardor  urinse  have  the  same  factors.  Dyspareunia  is  not 
uncommon  but  relative  rather  than  absolute.  The  objective  local 
symptoms  are  physical,  sensory  and  functional.  Enlargement  of  the 
duct  of  the  gland  on  one  or  both  sides  is  absent,  because  the  drainage 
is  free  and  efficient.  Pain  and  tenderness  are  marked,  but  much  less 
than  in  adenitis  with  occlusion,  because  pressure  of  abscess  formation 
is  lacking.  The  use  of  the  speculum  is  ordinarily  impossible.  Dis- 
charge is  copious  on  pressure  because  the  gland  always  contains  a  little 
residual  pus  which,  having  failed  to  drain  away,  is  easily  evacuated 
with  the  fingers  through  the  free  duct. 

Acute  vestibular  adenitis  tvith  occlusiori  also  has  sensory  and  functional 
disorders  as  the  subjective  local  symptoms,  which  follow  the  same  rule 
of  prompt  invasion,  which  develops  rapidly  into  full  establishment. 
The  early  discomfort  becomes  the  intense  agony  of  abscess,  and  tender- 
ness with  it  often  compels  the  patient  to  go  to  bed.  Both  are  much 
increased  by  voluntary  or  passive  movement  but  decrease  by  recum- 
bence and  separation  of  the  thighs.  Discharge  if  present  is  not  from  the 
ducts  of  the  affected  gland  but  from  other  associated  gonococcal  lesions. 
Ardor  urinse  is  also  independent  of  the  adenitis.  The  objective  local 
symptoms  are  physical,  sensory  and  functional.  Enlargement  of  the 
gland  on  one  or  both  sides  is  early  and  progressive,  often  reaching  great 
size.  Pain  and  tenderness  are  very  marked,  and  increase  with  the 
prominence  of  the  tumor.  There  are  redness,  enlargement,  edema  and 
deformity,  so  that  the  cleft  of  the  vulva  is  pushed  to  the  opposite  side 
and  even  overlapped  by  the  swelling.  Fixation  of  the  skin  to  the  gland 
may  be  early  on  both  inner  and  outer  aspects  of  the  labium,  and  always 
occurs  where  the  abscess  points.  Examination  with  the  speculum  is 
absolutely  impossible  and  pressure  on  the  gland  does  not  produce  a 
gush  of  pus  from  it. 

The  subjective  and  objective  systemic  symptoms  of  both  forms  are 
those  of  any  severe  infection  or  abscess  and  are  moderate  or  marked 
according  to   circumstances:  chill   or  chilliness,   fever,   perspiration, 


606    RARE  FORMS  OF  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

anorexia,  nausea,  sometimes  vomiting,'  ami  diarrhea,  malaise  and  pros- 
tration. When  outlet  of  the  pus  is  secured  these  symptoms  decrease  or 
disapjiear. 

The  termination  in  mild  forms  is  a  subsidence  of  sym])t()ms  and  slow 
relief  of  discharge,  but  these  cases  are  very  rare  and  probably  not  gono- 
coccal. Tlie  average  -idenitis  without  occlusion  is  marked  and  its 
drainage  inditi'erent  if  the  duct  n>mains  patent  so  that  the  gland  be- 
comes a  sinus  with  a  long,  tortuous  outlet.  Adenitis  with  occlusion 
may  rupture  at  any  point  in  the  \ul\a,  \agina  or  rectum  and  likewise 
produce  a  sinus  or  pocket  or  fistula.  Thus  are  created  two  forms  of 
persistent  gonococcal  focus  which  may  go  on  to  chronic  disease. 

Chronic  vcstihiiJar  adenitis  is  characterized  by  constant  discharge 
with  or  without  rclai)ses  and  by  numerous  exacerbations  either  from 
imi)risonment  of  the  pus  or  from  })r()gress  of  the  disease  to  newer 
portions  of  the  gland.  The  gland  forms  an  indurated  mass  surrounding 
the  pocket  from  which  leads  the  sinus  formed  by  the  duct  or  by  the 
fistulous  tract  into  the  vulva,  vagina  or  rectum. 

Cystic  irstibiildr  adenitis  or  cj/st  of  the  vestibniar  glands  marks  the 
subsidence  of  a  mild  abscess  and  its  conversion  into  a  cyst  or  the  benign 
occlusion  of  the  duct  without  abscess.  There  is,  strictly  speaking,  no 
invasion  and  the  disease  is  chronic  and  detected  in  its  establishment  in 
small  cysts  during  a  gynecological  examination  or  by  the  patient 
objecti\'ely  rather  than  subjectively.  The  cysts  are,  subjectively, 
usually  painless  unless  large,  when  the  discomfort  is  a  dragging  rather 
than  an  acute  suffering.  The  sensory  symptoms  appear  on  j^ressure, 
motion  and  manipulation.  Large  cysts  cause  dyspareunia.  Objectively 
the  mass  is  smooth,  elastic,  tense  or  soft,  opaque  or  translucent,  imi- 
lateral  or  bilateral,  small,  of  the  duct  alone  or  larger,  of  the  gland. 
Great  size  is  sometimes  attained  equalling  that  of  the  patient's  fist. 
The  labium  is  deformed  and  distorted  and  the  vulvar  cleft  disi)laced  to 
the  other  side  and  the  contents  of  the  cyst  are  thick  and  gelatinous  or 
clear  and  hemorrhagic.  There  are  no  systemic  symptoms  of  any  kind 
unless  infection  is  added,  when  the  picture  is  that  of  acute  adenitis  with 
occlusion.  The  termination  is  very  rarely  spontaneous  absorption  of 
small  cysts  and  rupture  is  likewise  uncommon.  Infection  and  injury 
may  at  an>'  time  con\'ert  the  cyst  into  acute  abscess. 

Diagnosis. — The  diagnosis  rests  on  the  fact  of  recent  or  old  infection 
in  the  history  followed  by  acute  or  chronic  tmnefaction  and  by  the 
subjective  signs  of  pain  and  discharge,  which  are  severe  in  suppurative 
adenitis  without  occlusion,  still  more  severe  in  the  form  with  occlusion 
but  indifferent  in  cyst.  Objectively  are  foimd  the  swelling  and 
deformity,  the  infiltration  and  free  discharge  on  pressure  in  adenitis 
without  occlusion,  but  the  swelling  and  the  changes  in  the  annexa  in 
abscess  without  a  stream  of  pus  on  palpation.  Cyst  resembles  the 
latter  with  all  acute  symptoms  eliminated.  Aspiration  is  rarely  neces- 
sary and  in  these  days  not  often  practised  but  will  reveal  i)us  in  abscess 
and  thin  or  thick,  clear  or  turbid,  gelatinous  or  hemorrhagic  fluid  in 
cyst.    The  laboratory  will  detect  the  gonococcus  alone  or  with  the  colon 


GONOCOCCAL  VESTIBULAR  ADENITIS  007 

bacillus,  Staphylococcus  albus  or  no  organisms  according  as  the  case 
is  a  gonococcal  pure  or  mixed  inf(;ction  or  a  nongonococcal  pure  or 
mixed  invasion  or  a  cyst.  Smear  and  culture  must  always  he  made  for 
best  determination,  and  as  this  lesion  is  one  of  absorption,  the  gono- 
coccal complement  fixation  test  is  always  advised.  The  treatment  of 
incision  and  drainage  or  removal  of  the  gland  is  often  the  final  step  in 
exact  diagnosis  and  not  infrequently  in  differential  diagnosis. 

Differential  Diagnosis  concerns  only  cyst  of  the  gland  in  contrast  with 
labial  tumors,  vaginal  cysts,  hydrocele  of  the  round  ligament,  hernia 
without  or  with  cyst  of  the  vestibular  gland. 

Cystic  vestibular  adenitis  differs  from  labial  tumors  in  the  history  of 
acute  onset  associated  with  infection  or  of  chronic  onset  without 
infection;  in  its  smooth,  regular,  elastic  form,  situated  in  the  vestibule 
near  the  vagina,  attached  chiefly  or  solely  through  its  duct;  in  its 
comparative  painlessness  and  slow  increase  in  size  and  definite  outline, 
in  its  occasional  translucency  and  almost  invariable  fluid  contents  on 
aspiration.  The  labial  tumor  has  slow  onset,  occasionally  rapid  growth, 
irregular,  ill-defined  soft  or  hard  form,  and  any  situation  high  or  low, 
superficial  or  deep  and  likewise  variable  attachments.  The  author 
had  a  fibromyxoma  or  edematous  fibroma  of  the  labium  which  had  an 
offset  toward  the  inguinal  canal  much  resembling  a  hernia,  another 
backward  along  the  rectum  and  a  third  downward  into  the  base  of  the 
labium  and  the  perineal  body.  The  whole  formed  a  soft  elastic  mass 
slightly  changing  its  form  on  pressure,  thus  imitating  reducibility  and 
having  a  false  impulse,  thus  possessing  two  features  of  incarcerated 
hernia.  The  diagnosis  was  not  settled  until  the  operation.  Figs.  134 
and  135  show  the  front  and  back  views  of  the  gross  specimen. 

Vaginal  cyst  differs  from  cystic  vestibular  adenitis  in  hardly  any  respect 
except  that  of  location  in  the  vagina  rather  than  in  the  vestibule  and  in 
the  identity  of  the  gland  involved.  The  latter  point  often  cannot  be 
decided  until  treatment  is  instituted  by  open  operation. 

Hydrocele  of  the  round  ligament  differs  from  cystic  vestibular  adenitis 
in  the  one  detail  of  its  location  within  the  inguinal  canal,  at  the  super- 
ficial abdominal  ring  or  in  the  upper  regions  of  the  labium  ma  jus.  In 
other  respects  it  is  broadly  and  essentially  a  noninflammatory  cyst. 

Hernia  differs  from  cystic  vestibular  adenitis  in  its  history  of  slow  or 
sudden  strain  or  trauma,  in  its  dragging  pain,  in  its  tumor  which 
approaches  the  labium  from  the  inguinal  canal  above  or  from  the  thigh 
laterally,  rather  than  from  the  base  of  the  labium  internall}'  and  pos- 
teriorly; in  its  spontaneous  or  passive  reducibility  and  relapse  as  soon 
as  the  support  is  withdrawn  or  the  standing  posture  resumed;  in  its 
impulse  on  coughing  and  in  the  existence  of  a  canal  into  which  the 
finger  passes  after  reduction.  Irreducible  hernia  is  much  less  obvious, 
and  if  the  bowel  is  in  the  contents  of  the  sac,  elasticity  and  other 
symptoms  similar  to  cyst  may  be  present.  In  such  cases  treatment 
alone  is  the  distinction  at  operation.  If  cyst  of  the  vulvovaginal  gland 
is  associated  with  the  hernia  the  open  operation  is  the  one  means  of 
recognition. 


608    RARE  FORMS  OF  GOXOCOCCAL  IXFECTIOX  IX  THE   FEMALE 

Treatment.  Care  ol"  the  urethritis,  vulvitis  ami  va^-initi.s  are  the 
prophylaxis,  lint  onl\-  in  the  indirect  sense.  Freedom  from  clinging 
pus  around  the  vestihule  is  of  jn-iniarv  importance  and  douches  nuist 
not  he  so  strong  as  to  inllanie  the  nuu-osa  and  thus  cause  cheinieal 
iiillainniatiou   of   tlie   iluets.     Cleanliness   of   the   hands   i)rotects   the 


s 

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Vu,.  v.'A  F,,;.  i:;.-, 

Fk;s.  i;i4  and  l.-io. — Author's  caso  of  fibroniyxoma  of  the  laliiuin  niajus.  (iross 
specimen.  Fig.  1.34  shows  the  anterior  and  Fig.  135  the  posterior  .vdcw  of  the  tumor, 
whose  several  prolongations  were  distributed  as  follows:  .1,  prolongation  toward  the 
inguinal  canal;  B,  main  body  of  the  timior  in  the  labium  majiis;  (\  prolongation  toward 
the  thyreoid  foramen;  D,  prolongation  toward  the  rectum. 


eyes  of  the  patient  and  all  dressings  should  be  put  into  paper  bags 
and  burned.  The  abortive  measures  against  this  complication  are 
ineffective. 

Requisites  of  management  are  given  in  Chapter  IX  on  General  Prin- 
ciples of  Treatment  on  page  -183. 


GONOCOCCAL   VESTIBULAR  ADENITIS  009 

Curative  Treatment. — The  physical  measures  are  hydrotherapy  dur- 
ing the  acute  stages.  Douches  are  given  in  the  manner  descrihefl 
under  vaginitis,  but  with  a  small  rubber  catheter  whose  insertion  will 
cause  the  least  pain.  Vulvar  lavage  with  the  pitcher  and  douche-pan 
is  convenient  in  keeping  the  pudendum  clean.  Fitting  and  body  baths 
cannot  be  used  during  the  acute  stage,  but  they  are  comforting  to  the 
declining  period  of  patients  who  refuse  operation. 

The  medicinal  measures  have  little  direct  effect  on  the  lesion  except 
for  the  immediate  control  of  such  symptoms  as  pain.  Systemic  and 
local  administration  are  therefore  much  the  same  as  those  in  other 
acute  gonococcal  lesions.  Wet  dressings  regularly  applied  to  the  vulva 
may  reduce  the  cellulitis  accompanying  the  abscess  and  limit  even  the 
abscess  itself.  The  milder  lotions,  such  as  aluminum  acetate,  0  per 
cent.,  are  the  best.  Serumtherapy  may  be  tried,  but  in  the  present 
state  of  our  knowledge  promises  little.  The  serum  may  be  used  in  the 
acute  days  and  the  bacterin  in  the  presence  of  sinuses  and  chronic  abscess. 

Surgical  Treatment. — The  treatment  of  gonococcal  vestibular  adenitis 
is  purely  surgical  and  either  palliative  or  radical.  The  palliative 
means  consist  in  aspiration  of  the  cyst  followed  by  injection  of  a 
mild,  limited  caustic  such  as  nitrate  of  silver,  5  to  10  per  cent.,  a  few" 
minims  of  pure  carbolic  acid  or  tincture  of  iodin  and  the  like.  Obliterat- 
ing inflammation  may  follow  this  injection,  but  the  measure  usually 
fails,  because  the  numerous  acini  of  the  gland  not  involved  in  the  cyst 
escape  adhesive  closure.  The  cyst  itself  may  likewise  not  so  respond. 
Incision  and  drainage  of  the  cyst  also  fail  for  the  same  reasons.  The 
condition  is  not  unlike  hydrocele  in  the  male  in  these  peculiarities. 

The  operative  details  are  the  usual  preparation  of  the  field  and 
patient  as  preliminaries.  The  instruments  and  supplies  consist  of  a 
sharp  scalpel,  curved  scissors,  hemostats,  anatomical  and  toothed 
forceps,  small  sharp  and  blunt  retractors,  needles  and  needle-holder, 
sutures,  ligatures,  dressings  and  a  T-bandage.  In  small  cysts  the  anes- 
thesia is  local,  but  in  larger  specimens  it  must  be  general.  The 
lithotomy  posture  is  best  and  the  general  landmark  is  the  labium  majus 
containing  the  cyst,  made  tense  by  pressure  from  above.  The  incision 
is  preferred  from  above  downward  over  the  prominence  in  the  modified 
skin  a  little  in  front  of  the  duct  of  the  gland.  The  superficial  field 
contains  the  modified  skin  and  underlying  erectile  tissue,  which  is 
separated  from  the  cyst  in  the  deep  field  by  blunt  dissection  except 
where  bands  require  division.  No  buttonholes  of  the  outer  or  inner 
skin  should  occur.  With  care  the  entire  sac  may  be  removed,  but  if 
broken  its  extensions  must  be  carefully  clipped  away,  otherwise  a 
blind  pouch  and  a  relapse  will  ensue.  There  is  no  drainage  and  the 
wound  is  sutured  with  buried  catgut  in  its  depths  and  interrupted  or 
a  subcuticular  suture  closes  the  margin.  Compression  with  a  large 
dressing  prevents  the  formation  of  dead  spaces.  The  immediate  after- 
treatment  is  to  keep  the  dressings  clean  of  urine  and  feces  and  to  avoid 
infection  by  immediate  wet  dressing  at  the  earliest  sign.  There  is 
otherwise  no  special  feature  in  the  nursing,  diet  or  medication. 
39 


610  RARE  FORMS  OF  GONOCOCCAL  INFECTION  IN  THE  FEMALE 

Treatment  of  su])})iiiati\e  l)artli()liiiitis  is  likewise  purely  surgical 
and  has  no  palliative  means,  as  aspiration,  injection,  incision,  cauteriza- 
tion, curettement  and  drainage  all  fail.  Abortive  measures,  chiefly 
as  wet  dressings  promptly  and  persistently  applied,  may  stop  an 
infected  gland  from  becoming  an  abscess.  The  operative  means  are 
in  every  detail  the  same  as  those  just  described  for  cyst  of  the  gland. 
The  presence  of  pus  makes  the  blunt  dissection  more  difficult  in  the 
acute  cases,  but  the  infiltrations  and  adhesions  may  be  overcome  with 
l)atience.  Chronic  abscess  is  the  form  most  often  submitted  to  inter- 
vention and  is  dealt  with  in  the  same  way.  It  is  occlusion  of  the  duct 
in  chronic  abscess  which  usually  leads  to  cyst,  with  which  it  is  surgically 
identified.  On  account  of  the  pus  present  the  cavity  of  the  wound 
should  be  swabbed  with  the  tincture  of  iodin  and  a  small  drain  inserted. 

Ajtertrcaimcni. — Drainage  and  dressings  with  care  of  the  urethritis 
and  the  vaginitis  are  the  immediate  aftertreatment.  The  drainage 
must  be  free  and  imobstructed  and  the  dressings  frequently  changed 
for  cleanliness  and  in  protection  of  the  opposite  gland.  Urine  and 
feces  must  be  carefully  removed  by  lavage  with  pitcher  and  douche-pan. 
All  the  measures  described  for  the  treatment  of  lu'ethritis  and  ^•aginitis 
must  be  continued.  Remote  aftercare  is  concerned  in  the  treatment 
of  the  last  two  conditions  which  often  persist  after  the  glands  have 
recovered.  The  opposite  gland,  if  normal,  should  be  kept  so  by  all 
these  measures. 

Cure. — Removal  of  a  cyst  of  the  vestibular  gland  cures  the  cyst  in 
the  pathological  sense,  but  not  the  gland  which  must  be  sacrificed. 
These  same  truths  apply  to  abscess  of  the  gland.  Symptomatic  cure, 
however,  is  of)tained  in  almost  every  instance  of  both  lesions  and  means 
healing  without  sinus  or  relapse  and  with  as  little  destruction  and 
damage  to  the  labium  as  possible.  Bacteriological  cure  implies  absence 
of  infection  in  the  gland  if  not  the  subject  of  operation,  in  its  fellow 
and  in  the  antecedent  lesions.  Hematology  must  show  a  negative 
complement  fixation  test.  Vestibular  adenitis,  especially  if  old,  may 
give  a  positive  test. 

GONOCOCCAL  INTRAMURAL  UTERINE  ABSCESS. 

Synonym. — Intramural  uterine  phlegmon. 

Significarce  and  Occurrence.- — Deep  suppuration  and  septic  process 
mark  the  im])ortance  of  this  rare  condition. 

Varieties. — Nongonococcal,  due  to  the  ordinary  organisms  of  pus 
and  gonococcal,  due  to  the  gonococcus,  are  seen. 

Pathology. — Intense  endometritis  and  metritis  finally  focalize  into 
true  abscess. 

Symptoms. — A  severe  gonococcal  invasion  is  followed  by  marked 
uterine  sym])toms  and  then  by  the  septic  abscess. 

Diagnosis. — Full  recognition  is  possible  only  at  operation  or  patho- 
logical examination.  A  })rominent  swelling  of  one  portion  of  the  womb 
is  suggestive.    Presence  of  the  gonococcus  is  essential. 


GONOCOCCAL  ASSOCIATED  INFECTIONS  01 1 

Differential  Diagnosis. — Distinction  is  necessary  between  abscess  and 
salpingitis,  degenerating  myoma  and  torsion  of  ovarian  tumors,  as 
shown  in  special  works  on  gynecology. 

Treatment. — Surgical  measures  alone  avail.  If  thoroughly  walled  u\\ 
by  adhesions  the  abscess  may  be  evacuated,  otherwise  hysterectomy  is 
necessary. 

III.     RARE  FORMS  OF  GONOCOCCAL  INFECTION  IN  THE 

FEMALE. 

Classification. — As  already  stated  in  previous  paragraphs  on  general 
significance,  the  subdivisions  are  two:  genital  and  extragenital.  For 
our  purposes  only  the  more  important  of  the  genital  group  will  be  con- 
sidered, such  as  hydrops  tubse  profluens,  torsion  of  gonococcal  uterine 
annexa,  hernia  of  gonococcal  annexa,  associated  infections  and  gono- 
coccal tubal  pregnancy.  Likewise  only  the  chief  extragenital  con- 
ditions will  be  noted,  such  as  rupture  of  gonococcal  foci  and  gonococcal 
general  peritonitis. 

Clinical  Features. — Founded  on  the  gonococcus  as  the  causative 
organism,  the  pathology,  symptoms,  diagnosis  and  treatment  of  all 
these  lesions  are  the  same  as  those  from  other  causes.  Each  is  fully 
described  in  special  monographs  on  diseases  of  women. 

GONOCOCCAL  ASSOCIATED  INFECTIONS. 

Definition. — By  this  title  of  gonococcal  associated  infections  is  meant 
chiefly  cases  in  which  other  organisms  attack  the  parts  after  the  gono- 
coccus has  been  present.  It  also  means  cases  in  which  the  gonococcus 
directly  associated  with  other  pyogenic  organisms  becomes  inoculated 
at  practically  the  same  time.  It  may  be  applied  likew'ise  to  those  cases 
in  which  the  gonococcus  is  not  the  antecedent  but  the  subsequent 
invader  after  the  other  organisms  have  had  their  day. 

Occurrence. — The  condition  is  not  by  any  means  uncommon,  and  as 
more  careful  bacteriological  study  is  done  it  will  undoubtedly  be  found 
still  more  common.  Mixed  infections  in  fresh  cases  with  great  activity 
of  the  gonococcus  are  rare,  but  become  more  frequent  with  the  duration 
of  the  gonococcal  disease. 

Etiology. — As  shown  in  the  definition  the  gonococcus  is  usually  the 
primary  organism,  alters  the  local  health  of  the  mucous  membrane  and 
lessens  the  resistance  so  that  the  other  organisms  have  free  action. 
The  pyogenic  organisms  are  the  most  common  associates,  particularly 
the  streptococcus,  staphylococcus  and  colon  bacillus.  The  Bacillus  of 
tuberculosis  is  by  no  means  unusual.  All  the  other  predisposing  and 
exciting  local  and  systemic  causes  described  under  etiology  in  the  male 
and  female  apply  with  added  force  in  these  associated  invasions. 

Pathology. — All  the  various  details  described  under  this  general 
subject  in  the  male  and  in  the  female  are  present,  adding  the  effect  of 
the  new  organisms  in  their  pyogenic  role,  combining  with  or  following 


612     RARE  FORMS  OF  GOXOCOCCAL  IXFECTIOX  IX  THE  FEMALE 

upon  the  effects  of  the  gonococcus.  If  the  associated  organism  is  the 
Bacilkisof  tuberculosis  then  the  particular  lesions  of  thisdisease  are  found. 

Symptoms. — Nothing  may  be  added  to  the  previous  pictures  drawn 
for  the  gonococcal  disease  itseU'  except  in  the  case  of  tuberculosis, 
which  must  have  its  typical  chronicity  and  tendency  towaid  dull  or 
active  pain  and  depreciation  of  health  seen  in  the  disease. 

Diagnosis. — All  the  other  elements  shown  in  gonococcal  infection  are 
used.  The  laboratory  ])resents  the  best  evidence,  but  if  the  other 
organisms  occur  with  the  gonococcus  they  may  overgrow  it  in  culture 
and  mask  its  presence.  In  some  of  these  cases  the  gonococcal  comple- 
ment fixation  is  ]wssible  and  valuable. 

Treatment,  Aftertreatment,  Cure  are  the  same  as  those  already  shown 
for  j)urc  gonococcal  disease. 

GONOCOCCAL  GENERAL  PERITONITIS. 

Gonococcal  Local  Peritonitis. — This  subject  is  fully  included  under 
Tubal  and  ()\arian  Disease  and  will  therefore  be  otherwise  omitted. 

Occurrence. — Gonococcal  infection  of  the  general  peritoneal  cavity  is 
rare,  chiefly  because  of  the  plastic  tendency  of  the  inflammation  to  wall 
oft'  the  point  of  onset  and  thus  limit  it  chiefly  to  the  pelvis.  Its  existence 
is  be>'ond  doubt  through  modern  bacteriological  researches. 

Etiology. — After  the  play  of  all  the  piedisposing  and  exciting  local 
antl  systemic  factors  described  under  etiology  in  general  in  the  male 
and  female,  there  follows  decreased  resistance  and  penetration  into  the 
peritoneal  cavity.  The  peculiar  exudative  and  circulatory  conditions 
in  menstruation  and  the  puerperium  are  contributing  causes.  The 
gonococcal  pus  is  evacuated  upon  the  peritoneum  directly  by  leakage 
or  rupture  of  a  tube  following  torsion,  pressure  or  other  direct  action. 
A  few  cases  have  been  determined  by  infection  through  the  lymphatics 
and  still  others  by  direct  continuity  of  the  mucosa,  with  the  serosa  at 
the  fimbriated  extremity  of  the  tube.  Perhaps  the  smallest  number 
are  operative  accidents. 

Pathology. — All  the  various  lesions  described  in  the  male  under  this 
subject  apply.  In  general,  gonococcal  peritonitis  shows  fewer  macro- 
scopic lesions  than  do  other  purulent  forms.  The  membiane  is  red- 
dened, coated  with  comparatively  little  pus  and  forms  adhesions  early. 

Symptoms. — The  syndrome  of  invasion  and  establishment  noted  on 
page  218  for  this  complication  in  males  may  be  applied  for  woman,  and 
in  general  are  those  of  any  other  peritonitis  with  a  tendency  toward 
decreased  severity.  Its  onset  is  in  the  pelvis,  where  the  earliest  and  most 
intense  and  usually  the  most  persistent  symptoms  are  found.  It  ditiers 
from  peritonitis  in  the  male  chiefly  in  a  rather  definite  record  of  pre- 
liminary tubal  disease  followed  by  rupture  and  infection.  The  termi- 
nation is  rather  more  favorable  than  other  forms  of  peritonitis.  With 
the  subsidence  of  the  severe  symptoms  appear  those  of  adhesions  with 
a  long  and  various  line  of  digestive  and  other  disturbances,  as  already 
shown  in  pelvic  peritonitis. 


GONOCOCCAL  INFECTION   DUIilNG  PUERPERIUM  013 

Diagnosis. — All  the  other  elements  of  proof  are  applied.  The  history 
shows  early  venereal  infection  of  gonococcal  type  followed  by  the 
symptoms  of  progressing  involvement  of  the  internal  organs  and  then 
by  a  sudden  onset  of  the  peritonitis.  The  gonococcal  complement 
fixation  test  may  be  of  great  value.  The  laboratory  must  establish  the 
gonococcus  in  the  genitals  and  peritoneal  exudates.  The  treatment 
usually  shows  the  nature  of  the  infection  and  provides  exclusive 
specimens. 

Treatment. — As  in  local  peritonitis  incident  upon  tu})al  disease,  so  in 
general  peiitonitis  the  same  elements  of  treatment  apply  and  need 
not  be  repeated  as  to  prophylaxis,  management,  physical  measures, 
medicinal  measures  and  nonoperative  surgery.  If  the  gonococcal 
nature  of  the  lesion  is  fully  established  then  operative  surgery  may 
wisely  be  delayed.  All  the  reasons  and  conclusions,  advantages  and 
disadvantages  for  such  delay  have  been  desciibed  under  gonococcal 
tubal  disease.  The  general  results  of  such  late  surgery  are  likewise 
the  same,  and  in  the  average  case  are  better  than  early  operations. 
From  these  facts  it  follows  that  conservative  technics  are  far  better 
for  the  patient  than  radical  steps. 

GONOCOCCAL  INFECTION  IN  PREGNANCY,  DELIVERY  AND 
CHILDBED;  GONOCOCCAL  INFECTION  IN  PREGNANCY. 

Occurrence. — Gonococcal  infection  is  not  uncommon  among  preg- 
nant ignorant  women. 

Etiology. — ^The  pregnancy  is  the  only  new  factor. 

Varieties. — Severity,  progress,  extension  and  complications  are  the 
elements. 

Pathology. — ^The  lesions  in  the  external  organs  throughout  the  infec- 
tion and  those  in  the  uterus  after  childbirth  are  the  same  as  those  in  the 
nonpregnant  uterus,  but  more  severe. 

Symptoms. — Subjective,  objective,  local  and  systemic  data  obey  the 
same  rule  as  pathology. 

Diagnosis. — ^Establishment  of  the  gonococcus  is  essential. 

Treatment. — There  is  little  to  add  to  the  standard  management  of 
septic  postpartum  endometritis.    The  disease  is  grave  in  its  outlook. 

GONOCOCCAL  INFECTION  DURING  PUERPERIUM. 

Occurrence. — Childbed  infection  proceeds  from  recent  or  remote  foci. 
The  latter  class  is  common  among  supposedly  cured  cases  and  the 
former  among  the  ignorant. 

Etiology. — The  pathology  of  each  of  the  foregoing  forms  explains  the 
cause  fully. 

Pathology. — The  puerperal  state  is  engrafted  with  acute  gonococcal 
invasion  and  its  previously  described  lesions. 

Symptoms. — Early  and  delayed  invasions  are  seen,  otherwise  the 
disease  has  all  the  clmical  features  of  acute  endometritis. 


614    RARE  FORMS  OF  GOXOCOCCAL  IKFECTIOX  IX  THE  FEMALE 

Diagnosis. — (/hildhirth.  early  recovery  followed  by  acute  infection 
with  (iiscoN'cry  of  the  >i;onococcus,  prove  the  case. 

Differential  Diagnosis. — The  reader  is  referred  to  works  on  gyne- 
cology for  details.    The  conditions  are  of  two  classes: 

1.  Coiidiiioiui  Incident  to  Puerperinm. — Autointoxication,  caked  and 
infected  breasts,  sapremia  of  retained  secundines  and  accidental 
pyogenic   infection. 

2.  Conditions  Intercurrent  in  Puerperinm. — Torsion  of  ovarian 
])edicles  or  })us  tubes,  appendicitis,  typhoid  fever,  tuberculosis  and 
malaria. 

Treatment. — The  primary  focus  of  infection  must  be  located  and 
cured  while  the  septic  state  is  managed  by  methods  fully  described  in 
works  on  obstetrics. 

AGE  AS  A  FACTOR  IN  GONOCOCCAL  INFECTIONS. 

Significance. — Old  age  is  rarely  but  early  life  often  attacked. 

Gonococcal  Infection  from  Infancy  to  Puberty. — Occurrence. — 
(ionococcal  infections  hi  girls  are  common  through  normal  patency  of 
the  parts.  The  Micrococcus  catarrhalis  must  be  carefully  distinguished. 

Varieties. — The  same  sites,  courses,  extensions  and  organisms  are 
recognized  as  in  the  adult. 

Etiology. — The  gonococcus  is  of  chief  interest.  Cases  are  unexplained 
or  appear  after  birth  or  through  instrtmients  and  utensils.  Criminal 
intent  is  not  unconmion.    About  puberty  the  sexual  factor  appears. 

Pathology.^ — ^The  ordinary  lesions  are  seen,  followed  very  commonly 
by  arrest  of  uterine  development. 

Symptoms. — Subjective  symptoms  are  largely  lacking  except  crying 
dm-ing  urination.  The  other  factors  are  objective  proof  of  vulvo- 
vaginitis and  the  gonococcus. 

Diagnosis. — Careful  examination,  well-prepared  smears  and  cultures 
prove  the  gonococcal  origin. 

Treatment. — Prevention  is  important  through  precautions  in  every 
person  and  utensil  used  about  the  female  genitals.  Expectant  gentle 
measures  available  for  the  adult  are  indicated. 

GONOCOCCAL   COMPUCATIONS    FROM   INFANCY    TO    PUBERTY. 

Classij&cation. — As  in  the  adult,  the  genital  and  extragenital  forms 
are  recognized,  of  which  the  latter  includes  the  urinary  and  systemic 
tj-pes. 

A.    Urogenital  Group. 

I.     Genital  Forms. 

Significance. — Extensions  of  the  disease  along  the  mucosae  into  the 
internal  organs  as  puberty  approaches  are  not  strictly  complications, 
but  are  usually  so  described. 


GONOCOCCAL  INFECTION  AFTER  MENOPAUSE  615 

Clinical  Features  and  Treatment.^ — '^I'he  symj)torns  and  measures  are 
the  same  as  those  described  for  the  adult,  with  strong  emphasis  on 
conservatism. 

II.      Urinary  Forms. 

Significance. — Involvements  of  the  urinary  organs  are,  strictly  speak- 
ing, complications. 

Varieties. — Caruncle,  folliculitis,  adenitis,  cystitis,  ureteritis  and 
pyelitis  are  usual. 

Clinical  Features  and  Treatment.^ — The  symptoms  are  the  same  as  in 
adults  with  fewer  subjective  details.  Conservative  treatment  must 
predominate. 

B.    Extragenital  Group. 

Classification. — ^The  complications  are  termed  according  to  the 
systems  of  the  body. 

Clinical  Features. — Susceptibility  and  lower  resistance  in  childhood 
are  the  chief  distinctions  of  the  list,  including  chiefly  condylomata 
acuminata,  proctitis,  inguinal  adenitis,  vestibular  adenitis,  ophthalmia, 
arthritis  with  tenonitis  and  peritonitis. 

Treatment. — Measures  as  recommended  for  the  adult  are  employed. 

GONOCOCCAL  INFECTION  AFTER  MENOPAUSE  AND  IN 

OLD  AGE. 

Occurrence. — Compared  with  midlife  the  gonococcus  is  rare  after 
the  menopause  and  in  age.  The  infected  disloyal  husband  and  the 
ignorant  promiscuous  woman  herself  are  the  sources. 

Varieties. — Acute  infections  are  rare.  Subacute  and  chronic  con- 
ditions antedating  into  midlife  are  common. 

Etiology. — ^The  gonococcus  by  recent  advent  or  from  old  foci  is  the 
one  cause. 

Pathology. — On  the  basis  of  much  altered  organs  the  familiar  lesions 
are  seen. 

Symptoms,  Diagnosis  and  Treatment. — ^The  complaints,  proof  and 
management  of  these  infections  are  all  on  fully  established  lines. 
Prevention  is  important. 

Gonococcal  Complications  After  Menopause  and  in  Old  Age.— 
Physiological  alterations  of  the  organs  after  the  menopause  and  changes 
in  sexual  habits  make  complications  very  rare  indeed. 


CHAPTER    XII. 

URETHROSCOPY. 

Varieties. — As  in  many  other  departnu-nts  of  diagnosis  tlic  technic 
varies  between  the  sexes,  and  one  must  therefore  distinguish  urethro- 
scopy in  the  male  and  urethroscopy  in  the  female. 

I.     URETHROSCOPY  IN  THE  MALE. 

Urethral  Specula. — Excluding  the  urethroscope  specula  are  unim- 
portant through  difficulties,  illumination  and  magnification  for  diag- 
nosis and  treatment.  The  Skene-Folsom^  is  serviceable  in  both  sexes, 
aided  by  the  Chetwood  lamp.  Its  features  are  clear  in  Fig.  13G,  ]\]ore 
serviceable  is  the  author's-  short  urethroscope  based  on  Chetwood 's 
model,  with  centimeter  graduations  for  localization  of  lesions. 


Fig.  136. — Skene-Folsom'dilating,  adjustable,  wire  spring,  urethral  speculum. 

History. — The  points  of  advance  from  the  crude  to  the  perfected 
instrinnent  have  included  the  following  miportant  particulars: 

1.  The  source  and  position  of  the  light. 

2.  The  lens  system  for  magnifying  the  image. 

3.  Dilatation  by  air  or  water  for  separating  the  walls  of  the  urethra 
and  for  opening  folds,  recesses  and  pockets,  so  as  to  afford  as  nearly  as 
possible  the  normal  condition  during  function  of  the  urethra  and 
accessibility,  for  diagnosis  and  treatment. 

4.  Position  and  form  of  the  fenestrmn,  which  is  either  terminal  or 
lateral,  circular  or  oval,  large  or  small. 

The  earliest  conception  was  that  of  extrinsic  illumination.  The  first 
instruments  therefore  began  to  develop  this  detail. 


1  Diseases  of  the  Bladder  and  Urethra  in  Women,  1882,  p.  295. 

2  Pedersen,  V.  C:  Med.  Rec,  1913,  Ixxxiv,    1.58,   also  .Jour.   Am. 
Ix,  182. 


Med.   Assn.,   1913, 


URETIJfiOSCOPY  IN  THE  MALfJ  017 

Bozzini,'  of  Prague,  in  ISO?,  was  the  first  to  suggest  instrument ;i I 
illumination  of  the  body  eavities. 

Types. — Classification  embraces  primary  and  secondary  forms. 

I.  Primary  varieties  include  definite  uses: 
(a)   Examination. 

(6)    Treatment,  nonoperative  and  operative. 
II.  Secondary  varieties  comprise  the  structure: 

1.  As  to  means  of  vision: 

(a)   Tubular,  earliest  and  simplest,     NormuisnifyiriK  until    in  latest  models 

lenses  were  added. 
(h)    Telescopic,  containing  a  true  telescope,  rnaKnifyiriK  direct  or  lateral 

fields,  inverted  or  erected  images. 

2.  As  to  source  of  light: 

(a)  Extrinsic,  having  lamp  and  head  mirror  or  light  outside  of  sheath. 

(b)  Intrinsic,  having  lamp  integral  with  the  instrument  and  always  within 

the  sheath. 

3.  As  to  object  in  the  field: 

(a)   Inverting,  having  image  reversed. 

{b)   Erecting,  having  image  correct  in  relations  to  the  urethra. 

4.  As  to  position  of  field: 

(a)  Direct  or  axial,  with  field  directly  before  the  observer. 

(b)  Indirect  or  lateral,  presenting  field  at  right  angles  to  the  line  of  vision. 

5.  As  to  preparation  of  field: 

(a)  Nondistending,  without  means  of  filling  the  urethra. 

(b)  Distending,  with  air  or  fluid  through  inlet  but  without  separate  outlet. 

(c)  Irrigating,  having  inlet  and  outlet  faucets  for  distending  fluid. 

6.  As  to  fenestrum  or  opening: 

(a)  Terminal,  normal  or  oblique  to  the  axis  of  the  sheath. 

(b)  Lateral,  with  long  axis  anteroposterior  and  short  axis  invoh-ing  little 

of  the  circumference. 

Optical  Principles. — ^Tubular  urethroscopes  began  the  science  with 
no  lenses,  with  axial  vision,  extrinsic  illmnination,  at  first  with  not 
even  a  head  mirror  and  with  distention.  As  later  developments, 
lenses,  telescopes,  intrinsic  illmnination,  and  distention  were  devel- 
oped. Valentine's^  instrument  has  been  improved  by  Young,''  Squier, 
McCarthy,*  Hayden,^  the  author''  and  Buerger.^  The  telescopic 
instruments  have  true  optical  telescopes  with  magnified  inverted  or 
erected  images  in  lateral  or  axial  fields  under  intrinsic  illumination 
and  distended  in  lateral  or  terminal  fenestra.  Goldschmidt's*  urethro- 
scope has  been  perfected  by  Buerger^  and  McCarthy.  ^° 

Advantages  of  Extrinsic  Illumination  Urethroscopes. — ^The  limitations 
outweigh  the  advantages,  which  are: 

1.  A  full  lumen  for  instruments,  without  interference  by  a  light 
carrier. 

1  Weimar,  1807. 

2  Med.  Rec,  1895,  xlviii,  153  and  Med.  News,  1899,  Ixxiv,  158. 

3  Young:    Trans.  Am.  Urol   Assn.,  1909,  iii,  100. 

4  New  York  Med.  Jour.,  1910,  xcii,  1068.  s  Med.  Rec,  January,  1912. 
6  Pedersen,  V.  C:  New  York  Med.  Jour.,  October  19,  1912. 

'  Jour.  Urol.,  October,  1917. 

«  Fol.  Urol.,  1908,  ii,  704;  Ibid.,  1907,  i,  107;  Ztschr.  f.  Urol..  1909,  iii.  Beiheft  i,  p.  95. 

»  Jour.  Am.  Med.  Assn.,  1910,  liv,  1045;  Am.  Jour.  Surg.,  1915,  xxix,  54. 
^"  In  a  personal  letter  to  the  writer,  April  IS,  1917,  states:   "The  prismatic  instrument 
has  been  shown  before  various  societies — has  never  formally  been  published.     It   has 
been  in  use  for  the  past  three  years." 


GIS 


URETHROSCOPY 


^ 


ec 


WAPPLER   E,  M.     CO    INC.   NEW    YORK 
■rautcnARK 

itegd  USPO. 


<:"ftO 


Fig.  137. — Squier's  model.  Nondilating,  extrinsic  illuminating,  magnifying  type. 
./,  sheaths  with  obturators;  2,  obturator;  S,  sheath  with  lamp  and  lens.  (Courtesy  of 
Wappler  Electric  Company.) 


V  APPLE  R   E.Ni,do.N%W'Y()Rt 


W  Fig.  138. — McCarthy's  model.  Nondilating,  intrinsic  illuminating,  magnifying 
type.  1,  obturator;  2,  lamp  carrier,  lamp,  lens  and  conductor;  S,  anterior  urethral  sheath. 
(Courte.sy  of  Wappler  Electric  Company.) 


URErilROSCOPY  IN  THE  MALE 


619 


2.  A  large  field,  i(l(;ntifie(l  with  the  large  lumen  and  the  absence  of 
the  light  carrier. 


Fig.  139. — Hayden's  model.  Aerodilating,  intrinsic  illuminating,  magnifying  type. 
1,  anterior  obturator;  2,  anterior  sheath,  with  light  carrier,  lamp,  lens,  conductor  and  air 
bulb;  3,  posterior  urethral  sheath;  4,  obturator.  (Courtesy  of  Wappler  Electric  Company.) 

Disadvantages  of  Extrinsic  Illumination  Urethroscopes.— These  are  as 
just  stated  more  important  than  the  benefits  and  include: 

1.  Deficient  illumination,  because  light  varies  inversely  as  the 
square  of  the  distance. 


Fig.  140. — Young's  model.  NondUating,  extrinsic  iUuminating,  magnifjing  tj-pe. 
1,  obturator;  2,  sheath  with  lamp  and  lens;  3,  sheath  mth  obturator.  (Courtesj-  of 
Wappler  Electric  Company.) 

2.  Light  strong  enough  to  overcome  this  physical  loss  casts  reflec- 
tions from  the  telescope  and  confuses  the  eye. 


620 


URETHROSCOPY 


Fig.  141  Fio.  142 

Figs.  141  and  142. — IrriKatiriR,  cathetcriziag  and  operating  cystourethroscopes. 
Fig.  141.  Buerger  model;  Fig.  142,  McCarthy  model.  1,  telescope;  2,  sheath;  3, 
obturator.     (Courtesy  of  Wappler  Electric  Company.) 


Fig.  143.  —  Buerger  universal  cj^stourethroscope. 
1 ,  sheath  with  beaked  obturator ;  3,  light  carrier ;  a,  cuff ; 
h,  electric  coupling;  c,  locking  fork;  d,  irrigating  tube; 
e,  inlet  faucet;  S,  telescope  with  usual  fitting;  4'  sheath 
and  light  carriei  for  ordinary  aerodilating  urethroscopy 
or  Elsner-Braasch  cystoscopy;  a,  magnifying  window; 
5,  complete  urethroscope;  a,  instrument  tube,  mounting 
watertight  rubber  cap;  6,  urethroscope  with  filiform; 
7,  fulgurating  electrode;  S,  urethroscope  with  grasping 
forceps.     (Courtesj^  of  Wappler  Electric  Company.) 


622  URETHROSCOPY 

3.  Restricted  definition  through  tho  limited  lii::ht  and  the  rcllei'tions. 

4.  Difficulty  of  centering  the  rays  except  in  such  modern  instruments 
as  those  of  Squicr  and  Youn^:;. 

5.  The  eye  of  the  observer  must  maintain  constant  relation  with  the 
movements  of  the  ]iatient. 

6.  The  lamps  attached  narrow  the  lumen  for  instrumentatit)n  and 
nuist  be  removed  out  of  the  axis  of  the  sheath  accordingly,  even  in 
modern  instrmnents. 

Tlie  V.  C.  Pedersen^  instriunent  is  the  same  as  the  Chetwood, 
except  that  the  sheath  is  li,<,^htly  and  clearly  marked  for  subdivision 


Fig.  144. — Dr.  V.  C.  Pedersen's  urethroscope.  From  above  down  are  seen  a  sheath 
mounting  the  extrinsic  lamp  and  magnifjang  lens.  Below  this  are  the  intrinsic  lamps  for 
the  short  and  the  long  forms.  Next  follows  the  short  form  for  the  anterior  urethra,  then 
the  posterior  uretlu-a  model  with  oblique  fenestrum  and  finallj'  flic  ol)turator.  It  is 
noted  that  the  sheaths  are  marked  in  centimeter  subdi\isions,  permiding  localization 
of  lesions  from  one  treatment  to  the  next. 

into  centimeters  or  into  inches  and  half-inches.  The  scales  are  very 
serviceable  in  locating  and  relocating  lesions  which  require  treatment. 
Like  the  Chetwood  instrument  it  will  mount  the  Squier  light  and 
magnifier  for  appropriate  cases. 

Disadvantages  of  Water  Dilatation  Urethroscopes.  —  In  general  the 
same  six  objections  urged  by  Luys  against  this  type  of  instnmient  and 
abbreviated  in  this  work  by  the  author  in  the  notes  on  Goldschmidt's 
instriunent  apply  to  all  water  dilating  instruments,  but  the  advantages 
far  outweigh  them, 

I  Jour.  Am.  Med.  Assn.,  1913,  Ix,  182. 


URETHROSCOPY  IN  THE  MALE 


623 


Advantages  of  Water  Dilating  Urethroscopes. — The  author  would  point 
out  the  following  benefits  of  the  Buerger  and  other  instruments  which 
have  largely  adopted  its  design. 

1 .  The  optical  part  or  telescope  gives  the  best  possible  view  of  the 
field,  far  more  than  the  magnifying  lenses  in  the  extrinsic  illumination 
instnmients. 

2.  Its  devices  for  passing  and  directing  catheters,  wires  and  similar 
instruments  while  the  telescope  is  in  situ  permit  very  definite  treatment. 

3.  Irrigation  and  dilatation  with  water  remove  exudate  and  maintain 
the  most  normal  arrangement  of  the  mucosa. 

4.  The  lateral  fenestrum  both  by  withdrawing  and  rotating  the 
sheath  in  regular  sequence  from  point  to  point  explores  the  canal  most 
thoroughly. 


Fig.  145.- 


-Short  form  of  urethroscope;  a  modification  of  the  Chetwood  shown  beside  it 
in  comparison. 


5.  Removal  of  the  telescope  and  suction  and  drying  of  the  water 
from  the  field  and  application  of  a  magnifying  glass  as  suggested  by 
the  author  converts  the  instrument  into  one  for  treatment  through 
the  sheath  alone. 

Choice  of  Instrument.— In  selecting  a  urethroscope  the  author  believes 
that  both  kinds  should  be  at  service  and  therefore  recommends : 

1.  A  magnifying  air  dilating  terminal  fenestrum  instrument,  whose 
light  may  be  intrinsic  or  extrinsic  according  to  habit  and  preference  of 
the  operator. 

2.  An  intrinsic  illuminating  magnifying  water  dilating  lateral  fenes- 
trum instrument. 

Accessories  of  Urethroscopy.  In  addition  to  the  urethroscope  itself 
various  implements  are  necessary  for  the  light,  dilatation,  cleansing. 


024 


URETHROSCOPY 


applications  and  treatments.  The  liuht  in  the  ohl  style  of  instruments 
reqnires  a  good  lamp  and  a  head  mirror.  This  method  of  illumination 
is  obsolete  because  very  imsatisfactory  throu£:h  the  length  of  tube  and 
the  smallness  of  the  field.  In  the  new  t\'\)e  of  urethroscope  an  electric 
lain])  outside  or  inside  the  tube  is  sujiplied  with  ciu'rent  from  a  rheostat, 
eal)le  and  cutoiV.  The  dilatation  is  supi)lied  by  the  usual  bulbs  and 
tubing  in  the  air  instrmnents  which  are  less  and  less  employed  and  by  a 
Janet-Frank  or  similar  syringe  or  a  reservoir  irrigating  can  and  neces- 
sary tubing  and  comiections.  Cleansing  and  ai)i)lications  are  provided 
usiially  i)y  long  wooden  ai)])licators  and  cotton  swabs.  Water  may  be 
sucked  from  the  lU'cthroscope  by  means  of  a  soft-rubber  catheter  and 
syringe  or  various  special  instrimients  consisting  of  a  metal  tube  and 
bulb.  Treatment  is  medicinal  or  instrimiental  or  both.  The  drugs 
commonly  employed  are  styptics,  anesthetics,  stimulants  and  caustics. 
The  best  styptic  is  adrenalin  mopped  or  flooded  upoTi  the  surface  and 
then  dried.  Among  the  anesthetics  may  be  mentioned  alypin  2  per 
cent.,  eucain  2  per  cent.,  novocain  0.5  to  2  per  cent,  and  stovain 


Fig.  146. — Alexaiulor-.Iarict  Record  syringe,  showing  lock  ring  (c) ;  tip  and  union  disk  (b) 
ground-joint  mounting  (a). 


0.5  to  2  per  cent.  Stronger  solutions  may  be  employed  in  moderate 
quantities,  remembering  that  the  urethra  is  capable  of  very  rapid 
absorption  leading  to  toxic  results.  The  stimulants  and  caustics  are 
represented  by  nitrate  of  silver  as  the  best  of  all  in  strengths  varying 
from  1  to  500  to  10  or  20  per  cent.  The  instruments  are  syringes  with 
long  tips  for  injecting  follicles  and  large  syringes  for  irrigation.  The 
electrocautery,  high-frequency  machine  and  cables  are  important, 
while  scalpels  and  curettes  with  long  handles  complete  the  list. 

Basis  of  Success. — In  urethroscopy,  as  in  any  other  methods  of 
examination,  such  as  cystoscopy,  familiarity  with  the  mechanical  and 
electrical  details  and  skill  in  the  introduction  and  manipulation  of  the 
instrument  are  the  first  essentials.  To  these  are  added  complete  access 
to  the  canal  from  end  to  end,  dilatation  of  all  cavities,  recesses  and 
folds  with  separation  of  the  walls,  cleansing  of  exudate,  proper  magnifi- 
cation and  easy  means  of  treatment.  An  instrument  which  omits  any 
of  these  fundamentals  will  not  give  satisfactory  results. 

The  reader  is  reminded  that  many  instruments  of  historical  interest 
have  been  omitted  from  this  work  for  lack  of  space. 


URETHROSCOPY  IN  THE  MALE  G25 

Indications. — In  general  urethroscopy  is  indic-ated  in  all  forms  of 
chronic  urethritis  in  the  shred  stage  or  the  relaxed  purulent  stage, 
especially  when  these  have  been  resistant  to  other  forms  of  treatment. 
It  is  essential  that  the  infecting  organism  shall  have  become  attenuated, 
few  or  even  absent  and  above  all  that  the  irritability  of  the  canal  shall 
have  been  determined  as  very  little  to  invasion  by  catheter  or  sound. 
From  these  facts  it  is  obvious  that  any  acute  lesion  forbids  the  use  of 
the  urethroscope,  because  the  shoulder  between  the  sheath  and  the 
fenestrum  during  introduction  and  the  edge  of  the  fenestrum  during 
diagnosis  and  treatment  make  it  one  of  the  most  irritating  instruments 
to  employ  even  with  great  skill. 

A  careful  multiple  glass  test  should  precede  the  first  exploration. 
The  four-glass  test  of  Luys  is  serviceable  as  a  preliminary  index  but 
it  omits  any  exploration  of  the  prostate  and  seminal  vesicles.  The 
author's  seven-glass  test  is  therefore  to  be  preferred  because  it  will 
diagnose  lesions  in  these  organs  with  satisfactory  definiteness. 

The  significance  further  concerns  the  doctor,  patient  and  society. 
For  the  urologist  diagnosis  is  of  supreme  importance,  especially  if  it 
may  be  combined  with  treatment  by  direct  and  local  means.  These 
needs  have  stimulated  a  large  supply  of  instruments  which  may  be 
summed  up  by  those  of  mensuration  and  palpation  for  passage  through 
the  canal  and  location  of  the  lesion  and  by  those  of  instillation,  irriga- 
tion and  dilatation  for  treatment.  In  a  certain  sense  inexact  diagnosis 
and  empirical  rather  than  accurate  treatment  follow  their  use  when 
compared  with  the  urethroscope.  Good  light  and  a  proper  lens  system 
in  the  urethroscope  add  vision  to  all  other  methods  of  diagnosis,  and 
class  this  instrument  with  other  modern  inspection  devices  such  as 
the  proctoscope,  laryngoscope  and  ophthalmoscope.  Lesions  may  be 
exactly  located  and  recognized  as  to  nature,  such  as  exfoliations, 
ulcerations,  infiltrations,  granulations  within  the  urethra,  and  such  as 
glandular  disease  outside  the  urethra.  Treatment  may  be  selected  and 
applied  by  various  methods,  notably  chemical,  thermal,  mechanical  and 
electrical  means.  Surgical  procedures  such  as  incision  and  curetting 
may  be  carried  out.  Variations  in  treatment  in  the  choice  among 
the  foregoing  leading  methods  become  available  and,  what  is  equally 
important,  the  progress  of  treatment  is  noted  to  determine  the  time  and 
duration  of  rests  between  applications  and  the  incidental  and  terminal 
results. 

For  the  patient  satisfactory  knowledge  is  secured  as  to  why  his 
symptoms  continue,  why  relapses  occur,  why  complications  appear 
and  why  infection  may  persist.  These  important  questions  are  reached 
by  the  close  correlation  between  physical  examination,  urinalysis  and 
urethroscopy  whose  consistent  evidence  is  required  in  every  case. 

For  society  as  well  as  the  patient  the  urethroscope  determines  cure 
and  defends  the  victim  against  indefinite  course  of  his  disease,  the 
wife  against  innocent  infection  and  the  offspring  against  ophthalmia, 
vaginitis  or  similar  lesions.  Physical  examination  of  all  the  sexual 
organs  by  every  means,  digital  and  instrumental,  and  laboratory  exami- 
40 


626  URETHROSCOPY 

nation  of  urinr,  smears,  culture  and  blooil  is  a  step  in  tlie  process 
hardly  less  important  than  urethroscopy,  which,  however,  is  i)erha])s  the 
most  valid  of  all  because  it  locates  the  lesions  and  secures  the  s])eciinens. 
Cystoscojiy  must  often  he  added  to  urethroscoi)y  in  such  diagnoses. 
The  question  of  infectiousness  of  any  shreds  or  other  discharge  is  most 
important.  One  examination  by  any  sin<:^le  means  such  as  urethro- 
scopy is  misleadin<j  and  should  not  be  relied  on.  Most  authorities 
state  that  three  careful  iinestig-ations  should  be  consistently  ne<;'ati\"e 
to  smear,  culture  and  blood  test  and  that  the  inter\als  between  them 
should  be  not  short  and  uniform,  but  long  and  various.  The  author 
would  add  that  it  is  im])ortant  to  associate  with  such  examinations 
the  influence  of  all  imj)ortant  factors  such  as  deliberate  errors  in  diet, 
alcohol  and  as  the  influence  of  sexual  stimulation.  The  i)atient  should 
be  instructed  to  return  the  morning  after  a  seminal  emission  or  after 
intercourse  with  a  condom  in  circumstances  when  the  latter  test  may 
be  morally  emi)loyed  as  in  protection  of  the  wife.  It  is  a  well-estab- 
lished fact  that  the  male  and  female  (|uiescent  or  without  sexual 
stimulation  will  give  entirely'  diiVerent  specimens  from  men  and  women 
with  sexual  excitement.  This  physiologic  aid  should  always  be  invoked 
in  order  to  protect  the  reputation  of  the  urologist  for  accurate  diagnosis 
and  the  patient  and  society  against  innocent  infection. 

Contraindications. —  1.  Lack  of  knowledge  of  the  urethroscope 
and  its  accessories  leads  to  imperfect  application  and  misleading 
results. 

2.  Lack  of  experience  with  the  instriunent  causes  painful  introduc- 
tion, and  injiu-ies  which  may  suuulate  lesions,  especially  exfoliation  of 
epitheliiun  and  i)oints  of  hemorrhage. 

3.  Lack  of  previous  diagnosis  and  exploration  of  the  urethra  with 
bougies  and  sounds. 

4.  Lack  of  previous  acquaintance  with  the  nervous  and  other 
peculiarities  of  the  patient.  As  Luys^  says:  "It  is  reckless  to  urethro- 
scope inunediately  a  patient  whom  one  sees  for  the  first  time." 

5.  Acute  stages  or  sjonptoms  which  contraindicate,  also  all  other 
instnunentation  of  the  urethra. 

G.  Sj^ecial  symptoms  particidarly  chordee  and  tenderness  to  touch 
along  the  urethra  and  distinct  points  of  ardor. 

7.  History  of  frequent  relapses,  tending  to  show  active  or  easily 
provoked  foci. 

S.  Complications  in  their  active  or  subacute  forms,  particularly 
epididymitis,  i)rostatitis  and  cystitis. 

9.  Anatomical  defects  and  deformities,  especially  small  meatus. 

10.  Severe  sequels,  particularly  stricture. 

11.  Unfavorable  reaction  to  a  urethroscopy  forbids  another  for  a 
long  time. 

12.  Luys,  as  cited,  states  that  one  should  never  urethroscope  a 
urethra  which  has  not  been  previously  examined  and  well  dilated. 

'  A  Text-book  on  Goiionhca  and  its  Complications,  191.'i,  p.  1.55,  English  ed. 


URETJIIiOSCOPY  IN  THE  MALE  627 

Styptics  and  Anesthetics. — Adrenalin  in  reasonable  strength  may  be 
swabbed  on  a  given  point  or  in  less  strength  flooded  upon  the  surface 
of  the  field  and  then  mopped  away.  Bleeding  points  may  thus  be  con- 
trolled. The  disadvantage  is  that  the  anemia  resulting  from  the  vaso- 
constriction is  misleading  and  may  simulate  an  infiltration.  With  skill 
local  anesthetics  are  not  necessary  especially  if  the  passage  has  been 
accustomed  to  sounds.  Some  patients  require  injection  of  the  urethra 
with  alypin  solution  2  to  4  per  cent.,  which  is  held  in  a  few  moments 
before  using  the  instrument.  After  a  preliminary  smarting,  anesthesia 
is  induced  which  will  last  for  some  time.  Other  anesthetics  are  novo- 
cain, stovain  and  eucain  in  solutions  of  0.5  to  2  per  cent.,  cautiously 
applied.  Cocain  should  be  avoided  or  used  only  with  great  care  on 
swabs  and  in  weak  solution. 

Sterilization  and  Care  of  Urethroscopes  and  Accessories. — It  is 
well  to  have  a  full  equipment  in  both  private  and  hospital  practice. 
After  use  all  blood  and  pus  should  be  flushed  and  scrubbed  off  the 
instrimients  and  then  all  parts  which  may  be  boiled  should  be  sterilized 
in  this  manner.  Parts  which  may  not  be  boiled  may  be  thoroughly 
scrubbed  with  a  sterilized  brush  in  sterilized  water  and  green  soap. 
This  method  is  reasonably  efficient  and  nearly  as  good  as  boiling  if 
well  done,  as  determined  by  Chetwood,^  who  says  as  follows:  "As  to 
the  above  matter  you  are  quite  right  in  your  recollection  that  I  made, 
many  years  ago,  an  experimental  investigation  with  respect  to  the 
sterilization  of  gum-elastic  woven  instruments,  the  gist  of  which 
demonstrated  that  the  heads  of  catheters,  after  becoming  infected  with 
various  pathogenic  bacteria,  could  be  sterilized  with  tincture  of  green 
soap  and  a  scrubbing-brush,  so  that  no  culture  could  be  obtained  in 
bouillon  tube  or  agar."  Since  this  method  is  proved  concerning  cath- 
eters, it  follows  that  it  will  usually  be  reliable  for  nickel-plated  instru- 
ments which  may  not  be  boiled. 

The  author  keeps  all  urethroscopic  and  cystoscopic  instruments  in  a 
cabinet  in  which  formaldehyde  gas  is  generated  one  or  more  times  daily 
from  a  lamp.  Calcium  chlorid  in  a  glass,  renewed  from  time  to  time, 
absorbs  excess  of  moisture. 

In  hospital  practice  in  which  patients  are  often  examined  in  rapid 
succession  the  author  finds  the  following  plan  efficient  and  knows  of  no 
transferred  infections.  The  instruments  are  thoroughly  scrubbed  in 
warm  water  and  green  soap.  Watery  solution  of  green  soap  is  preferred 
because  the  tincture  attacks  the  cement  around  lenses  and  the  insul- 
lation  around  lamps.  They  are  next  washed  in  boric  acid  water  and  50 
per  cent,  alcohol  with  great  care  not  to  bring  the  alcohol  into  contact 
with  the  lenses  and  the  lamps  and  finally  they  are  immersed  in  carbolic 
acid  water  5  per  cent,  or  lysol  2  per  cent.  These  procedures  may  be 
done  while  the  patients  are  dressing  and  undressing  and  thus  loss  of 
time  prevented. 

Rough  handling  of  instruments  is  to  be  avoided  because  it  scars  the 

1  Personal  communication  to  the  author,  April  20,  1917. 


R28 


URETHROSCOPY 


nickel  finish,  and  dropping  will  dent,  buckle  or  bend  the  tube,  rendering 
them  useless. 

Technic  of  Urethroscopy.— The  elements  of  this  subject  are  the 
])rei)aration  of  the  room,  etiuipnient.  instruments  and  patient  and 
Hnally  the  introduction  and  application  of  the  instrument. 

Preparation  of  the  Room. — The  preparation  of  the  room  is  usually 
permanent  in  the  ofKce  and  hospital  but  in  private  houses  must  be 
ada])ted  to  conditions.  A  room  which  may  be  readily  darkened  and 
possesses  electrical  connections  and  washing:;  facilities  is  best.  Batteries 
must  be  taken  to  the  house  if  no  electric  facilities  are  at  hand.  Where 
the  room  cannot  be  darkened,  a  sterilized  dark  cloth  may  be  used  over 
the  head  of  the  operator  in  the  manner  of  the  photopjapher.  With  its 
aid  the  diagnosis  is  made  and  then  the  treatment  is  em])loyed  without 
this  im]H'diment.  In  hosi)ital  or  office  and  so  far  as  possible  in  private 
homes,  the  following  fioor  plan  should  be  followed  by  the  nurse  or 
assistant  who  prepares  for  the  urologist. 


Floor  Plan:  Preparation  for  Urethroscopy. 


Everything  Possible  Sterilized. 


Washstand. 
Brushes. 

Soap  bichlorid  solution. 
Lysol  solution. 
Boric  acid  solution. 


Operating  Table. 
2  or  3  pillows. 
Blankets. 
Kelly  pad. 
Stirrups  and  straps. 
Crank  handle. 
Pelvis  elevated. 
Head  high. 
Patient  comfortable. 


Nurse's  Table 
Towels. 
Sheets. 
Leggings. 

Perforated  towels.  Stools. 

Cotton  balls. 
Gauze  balls. 
Gauze  dressing. 
2  pus  basins. 
Tr.  green  soap. 
Bowl  boric  solution. 
9.5  per  cent,  alcohol.' 
Drinking  water.' 
Drinking  glass.' 
Drinking  tube.' 
Watch.' 

Assistant's  Table. 
Boric  acid  water. 
Bladder  syringe. 
Connecting  tube. 
Catheters. 
2  test  glasses. 
Lubricants. 
4  per  cent,  cocain.' 
2  per  cent,  alypin.' 
Styptics.' 
Stinaulants.' 
Caustics.' 

Sterilized  cystoscopic  dressing  set  contains  2  leggings, 
4  cotton  balls,  2  gowns  and  6  safety-pins. 


Electrical  Table. 
High-frequency  apparatus.' 
Generator.' 
Switch  board.' 
Battery  box.' 

Oper.\tor's  Table. 
Cystoscopes. 
Urethral  catheters. 
Ureteral  catheters. 
Extra  lamps. 
Rheostat  and  lamps. 
Black  cloth. 
Rubber  aprons. 
Gowns. 
Finger  stalls. 
Rublier  guard. 
High-frequency  cables.' 
Urethroscopes.' 
Applicators.' 
Special  instruments.' 
Transformer.' 


1  perforated  towel,  6  towels, 


'  On  special  order  only  for  special  cases. 


URETHROSCOPY  IN  THE  MALE  629 

Preparation  of  the  Equipment.— The  preparation  of  the  equipment  is 
largely  provided  for  in  the  foregoing  plan  of  the  room  and  makes  the 
instrmnents  and  supplies  accessible  to  the  operator,  assistants  and 
nurses.  The  author  prefers  his  own  table  (Fig.  194)  as  shown  under 
cystoscopy,  or  one  of  the  other  forms  of  light  adjustable  office  table. 
The  selection  of  the  urethroscope  is  according  to  the  caliber  of  the 
urethra  and  the  portion  to  be  chiefly  examined.  The  short  tubes  are 
serviceable  in  the  anterior  urethra  and  the  long  ones  in  the  posterior 
urethra.  Knowledge  of  the  caliber  of  the  canal  and  its  reaction  to 
instrumentation  is  essential.  A  preliminary  meatotomy  as  shown  in 
the  treatment  of  stricture  is  often  advisable  because  the  larger  the  tube 
the  more  definite  the  diagnosis  and  the  more  satisfactory  the  treat- 
ment. The  tube  and  its  obturator  are  assembled,  the  light  tested,  the 
freedom  of  working  parts  such  as  faucets  and  levers  proved,  and  the 
magnifying  lens  suitable  for  the  length  of  tube  ready. 

The  accessories  are  already  stated  in  a  previous  paragraph  on  this 
subject  and  include  swabs,  probes,  forceps,  knives,  scissors,  all  of 
urethroscopic  type,  chemicals,  styptics,  anesthetics,  high-frequency 
generator,  switch,  cables  and  ware,  cautery  points  and  controller  and 
finally  rheostat  for  controlling  the  light. 

Preparation  of  the  Patient. — ^The  preliminary  preparation  of  the 
patient  must  include  familiarity  with  the  meatus,  the  caliber  of  the 
canal  as  to  stricture  and  allied  lesions,  the  prostate,  the  testes  and 
finally  infection.  The  latter  is  all-important  because  accidental  infec- 
tion of  the  bladder  may  be  avoided  either  by  postponing  the  urethro- 
scopy or  by  extraordinary  care  of  the  bladder  after  it  if  the  lesions  show 
gonococci.  As  already  stated,  a  urethra  w^hich  has  been  repeatedly 
sounded  without  reaction  is  the  best  for  urethroscopy.  As  far  as 
possible  exudate  is  located  by  having  the  patient  attend  with  a  full 
bladder,  which  is  evacuated  through  the  tube,  as  urination  will  wash 
out  the  discharge  and  prevent  proper  observation  thereof.  This 
situation  is  analogous  to  that  in  the  female,  which  forbids  a  vaginal 
douche  before  examination. 

The  final  preparation  of  the  patient  includes  removal  of  the  clothing 
below  the  waist  and  adjustment  of  that  above  the  w-aist  m  order  to 
clear  the  genital  organs.  Leggings  such  as  are  showTi  in  Fig.  193  are 
serviceable  because  their  bag-form  covers  the  entire  lower  extremity 
and  their  wide  mouth  is  draped  above  the  pelvic  bones.  A  perforated 
towel  such  as  is  shown  in  Fig.  196  is  dropped  over  the  instrument  after 
insertion  and  adds  to  privacy  for  the  patient  and  comfort  for  the  doctor 
becausethepeculiar  odor  from  the  genitals,  especially  of  women,  is  largely 
removed  by  the  towel.  With  the  same  objects  in  view  the  nurse  or 
assistant  should  w^ash  the  genitals  thoroughly.  jNIany  patients  may  do 
this  themselves  in  gross,  leaving  lavage  of  the  meatus  to  the  nurse  or 
urologist  in  fine.  The  patient  sits  on  the  edge  of  the  table  as  far  forward 
as  possible  without  slipping  off,  protected  by  sterile  towels.  His  feet 
are  placed  in  the  stirrups  shown  in  the  illustration  of  the  author's 
table.    With  the  crank  the  pelvis  is  elevated  until  the  meatus  is  at  about 


630  URETHROSCOPY 

the  level  of  the  observer's  e>"e  and  the  ])atieiit's  back,  head  and  neck 
are  made  conit\)rtable  with  pillows  ami  b\"  atljustnient  of  the  head-piece 
of  the  table.  While  the  surgeon  is  making  final  preparation  the  local 
anesthetic,  if  any,  is  applied.  The  author  is  inclined  to  use  less  and  less 
anesthetic  and  to  increase  his  gentleness  more  and  more.  For  the 
meatus  he  prefers  one  or  two  granules  of  neurocaine,  such  as  are  used 
by  dentists  for  the  ca^■ities  of  teeth,  consisting  of  cocain  grains  j.t  each 
and  })roviding  active  anesthesia  while  melting  in  the  mucus.  Eucain, 
novocain  and  stovain  ma>'  all  be  used  in  1  to  2  per  cent,  solutions. 
Alypin  2  to  4  per  cent,  in  soft  Irish  moss  jelly  is  very  .serviceable  for 
injecting  into  tlu>  urethra. 

Introduction  of  the  Urethroscope.  -  The  first  point  is  the  selection  of  the 
type  of  instrument.  The  author  believes  that  for  the  average  case  the 
best  preference  is  for  the  Buerger  or  INIcCarthy  intrinsic  illumination, 
water  dilatation  and  irrigation,  lateral  fenestrum,  magnifying  instru- 
ment. Both  gi\e  oi)i)ortunity  for  examining  the  bladder  ])articularly 
in  its  cervical  portion  and  the  urethra  in  all  parts  and  directions  during 
rotation  and  withdrawal  of  the  instrument  in  a  systematic  step  by  step 
method.  The  question  of  straight  or  curved  beak  instruments  should 
be  decided  in  fa\'or  of  the  former.  The  old  doctrine  that  passage  of  a 
straight  instrument  is  well-nigh  impossible  and  always  dangerous 
applies  only  to  the  novice.  It  is  the  straight  shaft  of  all  urethral 
instruments  which  rests  in  the  urethra  after  the  curve  has  reached  the 
bladder  and  no  one  has  asserted  that  this  straight  shaft  is  dangerous. 
Such  instruments  are  the  common  sound,  the  stone  searcher  and  the 
cystoscope.  Of  these  the  last  two  are  subject  to  liberal  and  frequent 
movements  of  the  shaft  in  the  urethra  and  always  without  difficulty  if 
skill  is  employed.  For  this  reason  the  w'riter  always  employs  only  the 
straight  urethroscope  in  both  sexes  and  would  em])hasize  the  following 
steps  of  its  passage  into  the  bladder.  The  largest  diameter  of  tube 
should  be  chosen  which  will  move  freely  within  the  canal. 

The  lubrication  of  the  meatus  and  the  instrument  is  very  important. 
The  writer  favors  official  glyceritum  boroglycerini  because  it  is  effi- 
ciently antiseptic  if  properly  protected  from  contamination,  is  fluid 
and  freely  soluble  and  does  not  irritate  the  urethra  as  much  as  glycerin 
often  does.  Iiish  moss  preparations  with  antiseptics  are  familiar,  but 
the  best  of  them  do  not  adhere  to  the  instrinnent  as  well  as  the  glycer- 
itum boroglycerini.  If  alypin  suspension  in  thin  Irish  moss  jelly  has 
been  used  as  a  local  anesthetic  no  other  lubrication  is  required.  Oils 
and  greases  are  not  advisable  in  most  cases,  because  they  often  smear 
the  lamp  and  lenses  and  render  the  field  very  indistinct.  On  the  other 
hand,  however,  the  writer  has  found  that  in  sensitive  urethne  white 
vaseline  may  be  smeared  on  the  shaft  ])roximal  to  the  fenestrum  and 
permit  practically  painless  examination.  Manifestly  this  detail  must 
be  omitted  if  treatment  other  than  operation  is  to  be  undertaken.  This 
detail  of  lubrication  is  especially  valuable  in  cystoscopy,  in  w^hich  the 
shaft  of  the  instrument  occupies  the  urethra  as  a  whole. 


URETHROSCOPY  IN  THE  MALE  631 

Steps  of  Introduction. — It  is  important  for  everyone  to  learn  tiie  st(;j).s 
required  for  introducing  the  instrument  with  a  straight  tip  or  a  curved 
tip,  so  as  to  take  them  always  gently  and  almost  subconsciously. 

A.  Technic  for  the  Straic/ht  Tip  Urethroscope. —  I.  The  patient  is 
placed  comfortably  and  fully  ]3repared  on  a  cystoscojjic  table,  with 
pelvis  elevated,  back  well  suj)porte(l,  knees  widely  separated  and  feet 
resting  in  the  stirrups. 

2.  The  patient  should  present  himself  with  a  full  bladder,  because 
this  is  a  guide  to  entrance  of  the  instrument  into  the  bladder  and  serves 
to  retain,  with  the  least  possible  disturbance,  much  of  the  exudate 
which  the  urine  would  flush  out  in  being  voided. 

3.  The  lamp  should  be  tested  to  show  that  the  entire  electrical 
equipment  is  in  working  order. 

4.  The  obturator  should  be  tried  in  order  to  be  certain  that  it  is  not 
gummed  in  the  tube  with  blood  or  exudate  improperly  removed  after 
the  preceding  case. 

5.  If  local  anesthesia  is  determined  on  it  must  be  applied  before  the 
lubrication. 

6.  The  urologist  stands  between  the  patient's  knees  and  grasps  the 
penis  with  the  left  hand  and  then  wipes  clean  with  gauze  the  glans  and 
meatus  and  finally  lubricates  this  opening  and  the  instrument  with 
boroglyceride  or  other  preparation. 

7.  As  in  passing  the  sound  four  manipulations  are  used,  which  are 
gravitation,  elevation,  depression  and  penetration. 

(a)  Gravitation  is  first  and  consists  in  allowing  the  instrument  to  slide 
into  the  canal  vertically  by  its  own  weight  until  it  reaches  the  bulb  and 
stops  there.  For  this  reason  the  largest  size  of  urethroscope  should  be 
used  which  will  thus  move  freely  along  the  canal.  The  old  teaching  to 
use  a  small  tube  is  now  disregarded. 

(b)  Elevation  comprises  supporting  of  the  beak  of  the  instrument 
against  the  arch  of  the  pubic  bone  so  as  to  lift  it  out  of  the  pouch  of  the 
bulb.  For  the  beginner  and  the  average  practitioner  this  is  best  done 
by  inserting  the  finger,  protected  with  a  rubber  finger-stall  or  glove, 
into  the  rectum  (Fig.  147).  The  tip  of  the  finger  is  hooked  sharply 
forward  around  the  sphincter  muscle  where  it  reaches  the  bulb  and 
feels  the  beak  of  the  urethroscope  and  supports  the  latter  against  the 
roof  of  the  urethra  and  the  pubic  aich  and  away  from  the  pocket  of 
the  bulb. 

With  later  experience  the  finger  may  be  placed  upon  the  perineum  at 
the  base  of  the  scrotum  and  perform  the  same  function  (Fig.  148). 
Deep  bulbs  always  require  rectal  guidance,  and,  on  the  whole,  this  is 
the  safest.  With  still  greater  skill  and  longer  experience  the  instru- 
ment may  be  passed  in  man}'  cases  without  either  rectal  or  perineal 
guidance. 

(c)  Depression  consists  in  carrying  the  eye-piece  downward  through 
an  arc  of  about  90  degrees  while  the  beak  rotates  under  the  pubic  arch 
upon  the  finger  until  the  shaft  has  the  general  direction  of  the  mem- 
branous urethra  into  which  the  finger  feels  its  slide. 


632 


URETHROSCOPY 


Tho  instriinu'iit  is  now  licKl  stationary  while  the  tin.uer  is  slid  along 
it  to  the  apex  of  the  prostate  and  stops  there. 


Fig.   147. — Rectal  palijation  and  depression. 


riG.   14S. — Perineal  palpation  and  depression. 

(d)  Penetration  is  the  last  detail  and  consists  in  passing  the  instru- 
ment along  the  finger  through  the  prostatic  urethra  to  the  neck  of  the 


URETHROSCOPY  IN  THE  MALE 


U.JO 


bladder,  where  the  cutoff  muscle  often  arrests  it  until  a  little  gentle 
pressure  carries  it  into  the  bladder. 

If  this  obstruction  by  the  muscle  is  unusual  it  may  be  concluded  that 
the  angle  of  the  neck  of  the  bladder  is  greater  than  in  most  subjects. 
Further  depression  of  the  eyepiece  and  elevation  of  the  Ijcak  u]jward 
toward  the  umbilicus  followed  by  gentle  penetration  completes  the 
passage. 

Each  of  these  steps  should  be  performed  deliberately,  uniformly, 
gently,  and  with  the  least  possible  pain  to  the  patient. 

On  entering  the  bladder  and  withdrawing  the  obturator,  urine 
immediately  flows  out.  Slight  further  withdrawal  of  the  sheath  checks 
this  flow  and  leaves  the  bladder  with  urine  in  it  for  flushing  the  urethra 
after  the  urethroscopy.  If  the  bladder  is  empty,  warm  boric  acid  water 
may  be  run  into  the  bladder  for  the  same  purpose. 


Fig.  149. — Insertion  of  telescope. 


The  lamp  is  next  attached.  If  of  the  intrinsic  type  it  is  best  placed 
along  the  upper  wall  of  the  sheath,  thus  affording  better  space  below  it 
for  instruments  and  observation  of  the  floor  of  the  urethra,  which 
commonly  contains  the  more  important  chronic  lesions.  The  magni- 
fying lens  is  focussed  as  the  next  procedure. 

The  exudate  is  studied  as  it  lies  on  the  surface  or  is  expressed  from  the 
mucous  glands  as  the  tube  is  removed,  and  then  it  is  mopped  off  with  the 
cotton  applicators  so  that  the  underlying  mucosa  may  be  inspected. 

If  the  instrument  is  of  the  water  dilatation  and  irrigation  type  the 
telescope  is  inserted  (Fig.  149),  the  exudate  noted  and  then  the  mucosa 
cleansed  by  turning  on  a  few  drachms  of  water.  From  time  to  time  in 
long  cases  the  bladder  must  be  protected  against  undue  distention  with 
irrigating  fluid  by  opening  the  vent  in  the  sheath  and  evacuating  the 
bladder. 


634  URETHROSCOPY 

The  same  processes  are  rei)eated  in  the  step  by  step  witlulrawal  of 
the  tube  at  the  rate  of  1  diameter  of  the  fenestrmn  at  a  tune  so  far  as 
possible,  because  the  fenestrum  represents  a  field,  and  one  should  study 
the  urethra  as  a  total  of  all  the  fields.  In  the  terminal  fenestrum  histru- 
ments  such  fields  are.  for  the  most  part,  presented  in  i)ers])ective  as  the 
instrument  i^s  withdrawn,  but  in  the  lateral  fenestruni  instruments  the 
field  is  stretched  across  the  opening  and  rotation  of  the  instrument 
through  an  arc  of  300  degrees  slowly  reveals  a  zone  around  the  entire 
canal. 

The  floor  of  the  urctlira  is  the  most  imjjortant.  csj)ccially  in  the 
posterior  urethra  and  in  the  anterior  urethra  along  the  bulb.  Mucous 
follicles  are  scattered  numerously  everywhere  along  the  roof  and  sides. 

The  objections  to  straight  beak  m-ethroscopes  are  usually  those  of 
theory,  inexperience  and  ])rcjudice.  As  already  stated,  it  is  the  straight 
shaft  of  soimds.  cystoscojx's,  stone  searchers,  stone  crushers  and  the 
like  which  without  difficulty  or  injury  rest  in  the  urethra,  during  all 
manipulations  with  them.  This  fact  shows  that  the  straight  urethro- 
scope may  be  passed  freely  and  used  readily  in  the  canal,  whereas  one 
with  a  cur\ed  beak  cannot  be  rotated  through  an  entire  circle  for 
studying  all  sides  of  the  canal  without  excessive  pain.  Some  of  these 
instruments,  such  as  the  Goldschmidt  and  Swinburne,  cannot  be 
rotated  at  all  on  account  of  undue  length  of  beak. 

B.  Technic  for  the  Curved  Tip  Urethroscope. — ^AU  the  steps  dupli- 
cate those  laid  down  for  the  passing  of  the  standard  lu'cthral  sounds 
and  need  not  be  mentioned  except  to  refer  to  the  foregoing  description. 

The  limitations  of  the  curved  beak  urethroscopes  have  already  been 
detailed  in  the  paragraphs  immediately  preceding.  It  follows  that  only 
the  floor  of  the  urethra  is  accessible  to  these  instruments,  so  that 
through  the  same  step  by  step  study  only  this  portion  of  the  canal 
may  be  investigated.  The  evidence  of  this  fact  is  the  introduction  by 
Goldschmidt  of  two  instruments,  one  with  a  curved  beak  for  the  pos- 
terior urethra  and  one  with  a  straight  beak  for  the  anterior  urethra. 
If  Goldschmidt  and  others  had  studied  the  technic  of  passing  a  straight 
instrument  gently  and  successfully  the  curved  urethroscope  woidd 
have  been  omitted. 

URETHROSCOPY  OF  THE  NORMAL  URETHRA. 

General  Principles. — The  anatomical  and  the  clinical  fcatin-es  must  be 
distinguished.  The  former  have  an  important  bearing  on  the  latter 
and  must  be  absolutely  familiar  to  the  lU'ologist,  otherwise  when  patho- 
logic conditions  are  found  confusion  will  arise  and  error  of  interpretation 
will  occur. 

Anatomical  Features. — Anatomical  features  had  best  be  considered 
from  the  standpoint  of  four  portions  of  the  canal,  in  much  the  same 
manner  as  the  bladder  is  subdivided  into  five  portions,  according  to 
the  recommendations  of  the  author.'  These  urethral  segments  are 
the  vesical  neck,  prostatic  urethra,  membranous  urethra  and  penile 
urethra. 

'  New  York  Med.  Jour.,  August  23,  1913. 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  635 

I.  In  the  vesical  neck  are  found  the  sphincter  muscle  thrown  into 
numerous  and  variously  deep  folds  and  the  uvula  of  the  bladder  con- 
tinuing caudad  into  the  crista  urethra.'. 

II.  In  the  prostatic  urethra,  which  is  about  1^  inches  long,  proceed- 
ing from  the  bladder  toward  the  meatus,  are  revealed :  the  crest  of  the 
urethra  continuing  the  uvula  of  the  bladder  and  merging  with  the 
colliculus.  In  this  body  are  the  utriculus  masculiims  and  the  two  ejacu- 
latory  ducts  and  on  each  side  are  the  prostatic  sinuses  showing  very 
numerous  prostatic  ducts. 

Along  the  roof  of  this  portion  and  the  side  walls  are  seen  numerous 
mucous  crypts,  and  more  prostatic  ducts. 

III.  In  the  membranous  urethra,  which  is  f  of  an  inch  long,  are  seen 
the  folds  of  the  compressor  urethrse  muscle  and  more  mucous  crypts. 

IV.  In  the  penile  urethra,  which  is  six  inches  long,  are  discerned 
the  bulb  thrown  into  numerous  folds  simulating  in  miniature  a  col- 
lapsed urinary  bladder.  It  occupies  about  one  inch  and  contains  the 
ducts  of  Cowper's  glands.  Next  follows  the  pendulous  urethra  for 
about  five  inches,  containing  in  any  aspect  mucous  glands,  the  lacuna 
magna  and  the  meatus.  The  mucous  follicles  in  health  are  scarcely 
visible,  but  the  author  has  had  one  man  never  infected  with  venereal 
disease  w^ho  showed  many  easily  seen  openings.  Large  follicles  may 
therefore  be  normal  in  a  few  subjects. 

In  order  to  provide  uniformity  of  record  and  observation  the  writer 
has  devised  and  for  many  years  employed  the  following  chart.  At  the 
bottom  of  the  chart  are  printed  the  seven  leading  characteristics  of 
lesions  which  must  be  looked  for  and  recorded.  Where  a  portion  of  the 
canal  is  normal  the  name  of  that  portion  is  simply  crossed  out  with  the 
pen  to  save  writing.  The  chart  has  anatomical  names  abbreviated  to 
save  space;  for  clearness  they  are  printed  out  in  the  following  copy: 

V.  C.  Pedeesen's  Urethroscopic  Record  Chart. 

Name. 
Urethroscopy.     Date. 

I.  Vesical  neck.  , 

(a)   Sphincter  muscle. 
(6)    Uvula  vesiciB. 
II.  Prostatic  urethra  (IJ  inch).     A.   Floor. 

(a)  Colliculus. 

(b)  Prostatic  sinuses. 

(c)  Right  ducts. 

(d)  Left  ducts. 

(e)  Middle  ducts. 
(/)    Utriculus. 

(g)    Right  ejaculatory  duct.  * 
(h)   Left  ejaculatory  duct. 
(B)  Roof. 

III.  Membranous  urethra  (finch). 

(i)    Compressor  urethrse  muscle. 

IV.  Penile  urethra  (6  inches). 

(j)    Bulb  (1  inch). 
(k)   Cowper's  ducts. 
(I)    Pendulous  urethra  (5  inches). 
(m)  Mucous  glands. 
(?i)  Lacuna  magna, 
(o)    Meatus. 
C^^olor,  vessels,  edema,  elasticity,  crj'pts,  growths,  ulcers. 


636 


URETHROSCOPY 


By  employing  abbreviations  this  urethroscopic  diart  nia>'  be  printed 
alongsiile  of  the  eystoscopie  ehart  shown  in  the  ('hai)ter  on  Cysto- 
scopy, so  that  the  record  of  both  examinations  ma\'  be  arranged  in 
parallel  cohmins. 


Floor 


Eoof 


Fig.  150  Fig.  151 

Figs.   1.^0  and  151. — V.  C".  Pedersen's  diagrams  of  the  male  bladder  and  urethra. 

In  order  to  plot  the  findings  of  the  examination  the  foregoing  dia- 
grams have  been  devised  by  the  author.' 

P'or  the  female  urethra  and  bladder  the  same  plan  may  be  followed 
as  designated  by  the  author.  It  must  be  remembered  that  the  female 
urethra  is  the  same  as  the  prostatic  urethra  without  colliculus,  ejacula- 

'  Log.  cit. 


URETHROSCOPY  OF  THE  NORMAL  URETHRA 


037 


tory  ducts,  utriculus,  prostatic  ducts  and  prostatic  sinuses.  Its  chief 
features  are  numerous  mucous  crypts  scattered  everywhere  and  the 
glands  of  Skene. 


Fig.  152  Fig.  153 

Figs.  152  and  153. — V.  C.  Pedersen's  diagram  of  the  female  bladder  and  urethra. 
Show  the  same  plan  of  topography  applied  to  the  female  bladder.  Without  necessity  of 
a  separate  cut  the  female  urethra  may  be  drawn  in  over  the  male  and  the  same  plan  of 
procedure  followed  as  with  Figs.  150  and  151.  There  may,  however,  be  some  physicians 
who  see  only  female  cases,  to  whom  Figs.  152  and  153  will  be  of  value. 


Normal  Clinical  Features  of  Urethroscopy. 

General  Considerations. — Like  the  anatomical  features,  the  urologist 
must  become  familiar  with  the  clinical  features,  first  the  normal  and 
then  the  pathological.  The  chief  details  of  such  knowledge  are  the 
mucosa  in  its  thickness,  attachment,  vessels,  color,  elasticity,  cr}T)ts, 
glands,  laxity  and  folds. 

The  thickness  varies  largely  with  the  individual.  The  mucosa  is 
always  a  delicate  membrane  which  must  be  approached  with  gentleness 
and  deliberation,  but  in  some  subjects  it  is  much  thinner  than  in 
others,  especially  if  it  has  never  been  diseased.  Contrariwise,  in  a 
urethra  which  has  been  often  infected  it  will  be  found  thick  and  dry  in 
some  places  much  more  than  in  others,  and  sometimes  great  extents  of 
the  canal  are  so  changed. 

The  attachment  of  the  membrane  to  the  underlying  parts  is  an 
accompaniment  of  the  thickness.  In  the  spongy  m'ethra  it  is  less  free 
upon  the  underlying  connective  tissue  than  in  the  bulb  where  this 
pouch  by  suffering  dilatation  requires  an  expanse  of  mucosa  which  lies 
in  folds  when  the  bulb  is  inactive.  iVs  the  mucosa  thickens  with  dis- 
ease such  freedom  is  reduced  and  even  lost. 

The  color  is  the  rosy  red  of  the  mucosa  ever^-^'here  in  the  body,  due 
to  great  vascularity  and  delicacy  of  the  overlying  epithelium.    Such  is 


63S  I'RETIIROSCOPy      . 

the  color  when  the  meatus  is  opened  and  naked-eye  inspection  used, 
but  wlien  a  urethroscope  is  introduced  its  own  pressure  or  that  of  tlie 
dilating  air  or  water  will  make  the  color  much  paler  and  sometimes 
patchy.  Less  commonly  the  instrument  will  cause  circulatory  obstruc- 
tion and  deeiKMiinir  of  the  color  to  a  livid  red.  Shiftiuij  of  the  instru- 
ment by  relievinjj  the  i)ressurc  will  chauirc  this  lividity  back  to  normal 
or  nearly  normal  hue. 

The  vessels  are  indistinct,  as  a  rule,  even  under  magnification,  but 
the  same  factors  which  change  the  color  will  bring  into  greater  or  less 
prominence  single  or  grouped  vessels,  which  will  stripe  the  field  in 
beautifid  and  various  figures.  Before  concluding  that  a  pathologic 
condition  exists,  the  instrument  must  always  be  shifted  or  the  amount 
of  dilatation  decreased  or  increased.  Prominent  vessels  which  do  not 
change  accordingly  may  be  regarded  as  associated  with  another  lesion 
whose  location  and  nature  nuist  be  sought. 

The  elasticity  consists  in  freedom  of  response  under  changes  of  the 
air  or  water  used  for  dilatation  and  under  shifts  of  the  instrument. 
The  folds  chiefiy  change,  and,  as  in  the  urinary  bladder,  show  the 
presence  or  absence  of  infiltration.  Necessarily  elasticity  is  combined 
with  the  features  of  thickness  and  attachment.  The  normal  urethra 
has  in  these  senses  no  fixed  parts,  but  bulges  into  the  tube  as  it  is 
advanced  or  recedes  from  it  as  it  is  withdrawn. 

The  crypts  and  glands  are  in  health  in\'isible  except  in  rare  cases. 
If  seen  they  look  like  small,  open  needle  pricks  scattered  everywhere  but 
chiefly  along  the  roof  of  the  pendulous  urethra  and  less  frequently 
along  its  sides  and  floor.  In  the  prostatic  urethra  they  seem  to  be 
chiefly  on  the  roof  while  the  ducts  of  the  prostate  are  mainly  on  the 
sides  and  floor.  The  author  has  had  one  man,  who  although  never 
having  had  venereal  infection  showed  along  the  roof  of  his  penile 
urethra  almost  as  many  large  cr^^ts  as  are  seen  after  a  urethritis. 
Such  an  observation  suggests  that  open  glands  may  be  normal  in  a  few 
patients. 

The  laxity  and  folds  of  the  mucosa  are  seen  chiefly  in  the  bulb  and 
membranous  urethra,  where  they  are  required  for  accommodating  the 
canal  to  muscular  action  and  dilatation  with  fluid  naturally  passing 
during  lu'ination  or  copulation.  They  would  be  present  in  the  ])rostatic 
urethra  were  it  not  for  the  fact  that  the  prostate  is  a  firm  body  and  has 
the  mucosa  relatively  closely  applied  to  it.  Its  own  diameter  is  such 
that  dilatation  is  already  provided  for  in  this  the  largest  part  of  the 
canal.  In  the  spongA'  urethra  the  mucosa  as  a  whole  is  deeply  folded 
to  the  vision  of  the  urethroscope.  There  are  also  a  few  transverse 
bands  which  cross  the  canal,  ])articularly  at  the  angle  between  the 
penis  and  scrotum. 

Field  of  the  Urethroscope. — The  field  of  view  of  the  urethra  is 
determined  by  the  form  and  position  of  the  fenestrum — roimd  or  oval, 
terminal  or  lateral.  The  form  of  the  fenestrum  is  of  little  influence 
unless  it  is  very  large,  as  in  the  Goldschmidt  instrument,  and  thus 
passes  somewhat  out  of  the  observer's  control. 


URETIIROSCOFY  OF  THE  FORMAL  URETHRA  639 

Terminal  Fenestrum  Instruments. — The  end  opening  gives  a  central 
image  or  figure  of  the  mucosa,  which  varies  between  a  cone  as  the 
instrument  is  withdrawn  and  a  dimple  as  the  instnunent  is  advanced. 
These  results  are  due  to  the  wall  as  it  recedes  from  the  mouth  of  the 
instrument  and  collapses  to  appose  its  surfaces,  thus  forming  the  funnel, 
or  are  due  to  the  elasticity  of  the  wall  as  it  gently  impedes  the  progress 
of  the  instrument  and  pouts  into  it  to  form  the  dimple. 

The  cone  is  like  a  funnel  and  has  its  apex  distal  and  its  base  at  the 
margin  of  the  tube  and  its  walls  extending  between  and  comprising 
the  mucosa  available  to  view.  Withdrawal  of  the  instrument  increases 
the  cone  by  making  tension  on  the  canal  while  penetration  reduces  it 
and  converts  it  into  the  dimple.  Traction  on  the  penis  and  tube 
together  so  elongate  the  cone  that  it  becomes  practically  tubular, 
with  its  apex  beyond  good  illumination  of  the  instrument.  The 
advantage  of  this  technic  is  that  glandules  if  diseased  form  little 
prominences  along  the  surface  as  it  recedes  into  darkness. 

The  cone  is  most  prominent  in  the  anterior  urethra,  and,  as  stated, 
consists  of  apex,  suiface,  margin  and  base.  The  apex  is  usually  not 
remote,  hardly  more  than  the  diameter  of  the  field,  and  according  to 
the  direction  of  the  tube  is  centric,  eccentric  or  absent,  and  may  be 
changed  from  any  one  of  these  three  to  any  of  the  other  positions  by 
twisting  or  shifting  the  fenestrum.  Its  surface  is  thrown  into  little 
folds  or  ribs  radiating  from  the  apex  to  the  margin  and  representing 
the  early  collapsed  condition  of  the  lining  at  the  apex  to  the  stretched- 
out  condition  at  the  edge  of  the  tube.  The  number  and  changes  of 
these  folds  are  signs  of  the  elasticity,  attachment  and  freedom  of  the 
membrane.  The  margin  of  the  cone  is  determined  by  the  edge  of  the 
instrument  and  the  base  of  the  cone,  as  a  geometric  entity,  is  absent 
because  it  corresponds  to  the  fenestrum  itself.  The  general  form  of 
the  cone  changes  with  the  segment  of  the  canal  under  examination  and 
from  behind  forward,  which  should  always  bje  the  manner  of  a  com- 
plete urethroscopy,  extending  from  bladder  to  meatus;  the  central 
figure  shows  the  following  differences : 

The  posterior  urethral  picture  is  semilunar,  determined  by  the  form 
and  size  of  the  colliculus  as  it  mounts  upward  against  the  roof  and 
pushes  it  away  from  itself.  The  membranous  urethral  feature  is  a 
richly  folded  wall  and  small  apex.  The  bulbous  urethral  figure  is  more 
or  less  a  vertical  slit  due  to  the  redundancy  of  the  canal  at  that  point. 
The  anterior  urethral  cone  has  an  oval  slit  for  its  apex,  which  is  due 
to  the  arrangement  around  the  fossa  navicularis  and  glans,  and  farther 
back  the  form  is  irregular. 

The  surface  of  the  cone  is  the  surface  of  the  mucosa  with  its  striations 
and  gloss.  The  radiating  folds  form  the  striations  and  are  few  or  many, 
prominent  or  slight,  according  to  the  freedom  of  the  mucosa  and  the 
size  of  the  tube.  They  may  be  made  to  disappear  at  will  by  shifting 
the  instrument  or  by  changing  from  withdrawal  to  penetration.  They 
are  also  due  to  the  vascular  arrangement  and  are  in  health  relatively 
slight.    The  gloss  is  the  normal  smooth  unbroken  epithelium  with  the 


640  URETHROSCOPY 

moisture  as  it  passes  across  the  field  under  the  ghire  of  the  Hght.  The 
membrane  in  healtli  appears  smooth  exactly  as  accessible  portions  are 
smooth  to  touch.  The  margin  of  the  cone  underlies  the  edge  of  the 
tube,  whose  pressure  changes  the  \ascularity  actuallx'  and  the  gloss 
ai)parently.  Whether  or  not  a  pathologie  condition  is  present  is  shown 
by  restoration  to  normal  as  the  instrunu'iit  is  shifted. 

Special  P"'eatitres  of  the  Normal  Urethral  Segments. 

Proper  Urethroscopy. — This  investigation  must  begin  at  the  neck 
of  the  bladder  and  end  at  the  meatus  so  that  in  regular  order  the  seg- 
ments are:  neck  of  the  bladder,  posterior  urethra,  membranous  urethra, 
anterior  urethra  and  meatus.  This  order  will  be  followed  in  the  descrip- 
tion. It  is  understood  that  in  health  all  the  features  of  the  mucosa 
are  present  and  that  such  factors  as  great  redness,  prominent  vessels, 
edema,  inelasticity,  discharging  crypts,  infiltration,  growths  or  ulcers 
are  all  absent. 

I.  Vesical  Neck. — After  brief  inspection  of  the  trigonum  and  ureters, 
for  which  the  cystourethroscopes,  such  as  Buerger's  or  McCarthy's, 
are  far  preferable  to  the  terminal  fenestrum  instruments,  the  vesical 
neck  comes  into  view  and  presents  the  sphincter  muscle  which  by  its 
purse-string  action  shows  numerous  deep,  longitudinal  folds,  and  the 
uvula  vesica^,  which  is  a  prominent  ridge  on  the  floor  passing  caudad 
out  of  the  bladder,  where  it  merges  with  the  crest  of  the  urethra. 

n.  Prostatic  Urethra. — The  floor  is  much  more  important  and  presents 
the  following  features  for  inspection.  The  crista  urethrae  continues 
from  the  u\ula  of  the  bladder  to  the  upper  margin  of  the  colliculus, 
which  is  .semiovoid,  with  its  long  axis  longitudinal,  its  short  axis  trans- 
verse and  its  half-axis  vertical.  It  is  normally  rather  pale  perhaps 
from  pres.sure  of  the  instrument  or  the  dilating  fluid.  Its  tunic  of 
mucosa  fits  firmly  and  .has  no  folds.  The  prostatic  sinuses  situated 
on  each  side  along  the  base  of  the  colliculus  are  potential  pockets  until 
opened  by  air  or  fluid.  Their  inner  walls  are  formed  by  the  colliculus 
and  their  outer  wall  by  the  lateral  lobes  of  the  prostate.  In  the  cavities 
of  these  folds  are  the  prostatic  ducts,  which  are  chiefly  right  and  left 
and  a  few  central.  They  are  spread  out  along  the  lateral  walls  of  the 
sinuses  and  around  the  base  of  the  colliculus.  A  few  of  them  occur  on 
the  roof.    In  health  they  are  scarcely  visible. 

The  utriculus  is  embodied  in  the  colliculus,  a  little  anterior  to  the 
summit  and  in  the  middle  line,  but  it  may  be  posterior  to  the  summit 
and  difficult  to  find  with  the  terminal  fenestrum  instrument.  Its 
opening  resembles  in  miniature  that  of  a  ureter.  Its  depth  is  little  or 
great  according  to  development  and  varies  from  about  0.5  to  2  cm.  or 
more.    In  disease  it  may  be  greatly  altered. 

The  ejaculatory  ducts  are  right  and  left  on  either  side  of  the  utriculus 
and  commonly  below  it.  'J'hey  likewise  resemble  in  a  still  further 
reduced  size  the  openings  of  ureters.  In  health  they  are  very  difficult 
to  see  and  resemble  minute  folds  longitudinally  placed.     In  disease 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  641 

their  alterations  involve  ^reat  changes  in  their  normnj,  smooth,  clean- 
cut  margins  exactly  as  those  of  the  ureter  are  profoundly  altered. 

Along  the  prostatic  urethral  roof  are  found  the  ducts  of  the  anterior 
lobe  of  the  prostate,  which  are  with  difficulty  visible  in  health  and  even 
more  so  than  those  of  the  lateral  lobes  in  the  prostatic  sinuses. 
Numerous  mucous  crypts  are  present  along  this  region,  which,  like 
those  elsewhere  in  the  urethra,  can  hardly  be  made  out.  Folds  in  the 
mucosa  are  also  common  in  this  region,  but  they  are  less  numerous 
and  deep  than  elsewhere  because  the  prostate  is  a  rather  rigid  body 
through  which  the  urethra  passes  with  its  lining. 

The  general  impression  of  the  prostatic  urethra  is  that  of  a  spacious 
more  or  less  fixed  pocket  or  segment  of  the  urethra. 

III.  Membranous  Urethra. — This  portion  is  only  three-quarter  inches 
long  and  is  confined  between  the  layers  of  the  triangular  ligament. 
The  fascicles  of  the  compressor  urethrse  muscle  throw  the  mucosa  into 
folds  although  this  segment  of  the  canal  is  held  by  the  ligament  as  the 
most  fixed  part  of  the  urethra.  Mucous  follicles  are  numerous  but 
difficult  to  locate  in  health.  The  muscle  and  the  ligament  both  hold 
the  tube  more  in  this  portion  than  elsewhere,  so  that  as  the  tube  leaves 
the  entrance  of  the  membranous  urethra  it  is  liable  to  jump  unless  the 
urologist  is  cautious  to  avoid  this  pain  for  the  patient.  The  general 
impression  of  the  membranous  urethra  is  that  of  a  fixed  deeply  folded 
canal. 

IV.  Penile  Urethra. — This  portion,  also  called  the  spongy  urethra, 
is  six  inches  long  and  includes  the  bulb  and  the  pendulous  urethra. 
The  bulb,  one  inch  long,  is  interesting  on  account  of  its  size,  depth  of 
folds  and  general  laxity,  closely  resembling  a  diminutive  urinary 
bladder.  Under  dilatation  its  folds  may  be  made  to  change  and  nearly 
disappear.  It  is  sometimes  so  deep  that  the  fenestrum  must  be  crowded 
into  it  for  illumination  and  inspection.  It  is  occasionally  so  shallow 
that  one  is  perplexed  as  to  its  limits.  Under  the  flush  of  irrigating 
water  its  walls  come  and  go  as  nowhere  else  in  the  canal — a  fact  which 
constitutes  the  chief  diagnostic  point  of  its  situs.  Mucous  cr\'pts  are 
numerous  and  the  ducts  of  Cowper's  glands  are  near  the  middle  line 
and  the  distal  portion  of  the  bulb. 

The  pendulous  urethra,  five  inches  long,  shows  a  more  constant 
cone  than  anywhere  else  in  the  urethra  and  its  apex  varies  in  general 
form  from  a  more  or  less  irregular  point  at  the  penoscrotal  angle, 
through  a  transverse  slit  along  the  middle  segment,  to  a  vertical  slit 
in  the  fossa  navicularis  and  meatus.  Its  walls  show  usually  the  most 
numerous  and  deep  folds  as  one  proceeds  caudad  from  the  bulb.  The 
only  exception  to  this  statement  is  the  bulb  itself.  In  the  fossa  navicu- 
laris the  folds  disappear  because  the  body  of  the  glans  supports  the 
mucosa  firmly.  The  absence  of  folds  is  the  diagnostic  point  of  this 
region.  Vascular  striae  vary  with  the  individual,  the  pressure  of  the 
tube,  the  traction  on  the  penis  by  the  lu'ologist  and  the  influence  of 
dilating  air  or  water.  They  may  be  most  clearly  outlined  as  hair-like 
capillaries  against  the  yellowish-red  mucosa  or  they  may  be  vessels 
41  "^ 


642  URETHROSCOPY 

01  much  larger  size  through  any  of  the  foregoing  factors.  Disease 
produces  profound  changes  which  should  ahvays  be  traced  to  their 
sources. 

The  lacuna'  of  Morgagni  are  present  almost  entirely  along  the  roof 
of  the  urethra.  They  may  be  few  or  many  according  to  the  anatomical 
development  in  the  individual.  In  health  they  are  not  very  distinct. 
The  case  noted  by  the  writer  on  page  l)4G  tends  to  indicate  that  the}' 
may  be  normally  very  large. 

The  glands  of  Littrc  arc  the  nuicous  cry])ts  or  follicles  and  are  neces- 
sarily scattered  everywhere.  Like  the  lacuna'  they  may  be  difficult 
to  see  in  health  or  may  resemble  imhealed  needle  pricks.  Disease  may 
profoundly  alter  them  and  their  annexa. 

The  general  impression  of  the  penile  urethra  is  that  of  an  elastic 
tul)c. 

Lateral  Fenestrum  Instruments. — The  side  window  changes  the  field 
materially  from  that  of  the  terminal  fenestrum  urethroscope.  The 
field  varies  according  to  the  size  of  the  window  and  shoM-s  neither  cone 
nor  dimple,  but  a  mucosa  stretching  along  the  urethra  and  itself, 
lax  or  tight  according  to  the  portion  under  examination  and  the  ])res- 
ence  or  absence  of  dilatation.  Such  a  field  might  be  called  a  diaphragm 
across  the  lateral  fenestrum,  just  as  the  collapsing  urethra  is  called  the 
cone  or  funnel  beyond  the  receding  terminal  fenestrum.  Rotation 
through  an  arc  of  300  degrees  at  a  given  point  of  the  canal  gives  a 
com])Iete  circular  zone  of  the  wall  at  the  same  point.  If  now  the  tube 
is  withdrawn  the  distance  of  the  long  diameter  of  the  window  a  new 
zone  is  reached  continuous  with  the  one  first  seen.  A  combination  of 
such  rotation  and  such  withdrawal  constitutes  step  by  step  study  of 
the  canal.  Instrmnents  with  unduly  large  fenestra,  such  as  the  Gold- 
schmidt,  present  more  mucosa  than  can  be  controlled  or  examined, 
because  illumination  and  magnification  cannot  be  applied  to  extensive 
regions.  The  telescope  in  having  a  fixed  focal  field  is  much  better 
suited  for  studying  the  whole  region  and  the  features  of  the  mucosa 
from  the  bladder  at  the  ureters,  trigonum  and  neck  to  the  meatus. 

If  one  W'ishes  to  study  the  floor  of  the  canal  first  from  end  to  end  it 
is  necessary  only  to  keep  the  fenestrum  in  the  middle  line  and  to  with- 
draw it  field  by  field.  At  other  visits  the  roof  and  the  sides  may  be 
individually  inspected,  but  the  author  prefers  the  step-by-step  com- 
bined rotation  and  withdrawal  method,  which  usually  completes  the 
work  at  the  first  examination. 

The  image,  with  the  exception  of  the  cone  and  the  radiating  folds 
with  their  respective  variations,  is  the  same  in  its  general  features  in 
the  lateral  field  instrument  as  in  the  terminal  view  lu-cthroscope.  One 
therefore  seeks  to  recognize  the  special  features  of  thickness,  attach- 
ment, color,  vessels,  elasticity,  crj^jts,  glands,  laxity,  folds  and  gloss. 

Familiarity  with  the  normal  urethra  is  very  important  and  can  be 
gained  only  by  persevering  examination  of  every  patient  possible  who 
has  ne\er  had  venereal  disease  but  who  offers  functional  disorders  as 
reasons  for  urethroscopy.     In  this  way  the  art  of  urethroscopy  is 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  643 

analogous  to  that  of  ophthalmoscopy,  prostoscopy,  rhinoscopy  and  the 
like,  in  all  of  which  the  normal  standard  is  learned  only  by  examining 
nimierous  patients.  In  the  same  class  also  is  found  digital  examination 
of  the  prostate  to  distinguish  the  normal  from  the  diseased  and  to 
acquire  diagnostic  and  therapeutic  skill. 

Pathologic  Clinical  Features  of  Urethroscopy. 

Varieties. — As  elsewhere  in  this  work  the  classification  into  gono- 
coccal and  nongonococcal  forms  will  be  observed.  The  type  taken  for 
standard  and  comparison  is  the  gonococcal.  The  other  lesions  are 
equally  important  although  relatively  uncommon. 

Gonococcal  Lesions  in  Urethroscopy. 

General  Considerations. — Each  of  the  features  mentioned  and  dis- 
cussed under  normal  urethroscopy  should  be  taken  up.  Convenience 
suggests  the  same  order  as  that  already  shown:  thickness,  attachment, 
color,  vessels,  elasticity,  crypts,  glands,  laxity,  folds  and  gloss. 

Thickness. — According  to  degree  and  age  of  the  inflammation  the 
density  of  the  mucosa  changes  from  a  relatively  soft  edema  and  infil- 
tration of  the  subacute  stage  to  a  dense  replacement  of  the  mucosa  in 
hard  infiltration  and  stricture.  Both  are  accompanied  by  glandular 
changes  of  the  common  types — namely,  those  without  occlusion  of 
ducts  and  retention  of  secretion  and  those  with  both  phenomena  as 
later  discussed  under  the  heading  of  glands. 

Attachment. — Where  thickness  has  been  increased  and  the  mucosa 
has  lost  all  apparent  freedom  of  motion  on  the  underlying  tissue  the 
attachment  may  be  regarded  as  close.  There  is  no  change  in  the 
terminal  or  lateral  picture  of  the  mucosa  in  response  to  fluid,  as  it  runs 
into  the  canal  or  as  the  membrane  recedes  from  the  instrument  as  it 
is  withdrawn. 

Color. — The  fine  fibrillation  of  capillaries  of  the  normal  mucosa 
changes  to  hyperemia — passive  or  active.  Passive  turgescence  is  seen 
usually  caudad  to  an  obstruction  and  in  the  urethra  it  is  common  in 
association  with  stricture  and  is  comprised  chiefly  of  venous  engorge- 
ment. Active  hyperemia  is  seen  cephalad  to  stricture  where  the  more 
active  inflammation  is  still  existent,  and  it  consists  chiefly  in  arterial 
capillaries.  Around  granulations,  glands  and  other  chronic  changes 
this  process  is  often  present.  Pallor  indicates  obliteration  of  vessels 
by  cellular  proliferation  such  as  embodies  a  stricture. 

Vascularity. — Changes  in  the  bloodvessels  accomit  for  those  m  color 
and  are  therefore  hand  in  hand  with  all  the  foregoing  factors.  Passive 
hyperemia  shows  obstruction  which  is  cephalad  to  it,  while  active 
turgescence,  on  the  other  hand,  is  found  where  inflammation  is  going  on 
so  that  it  appears  with  glandular  disease  and  cephalad  to  infiltrations 
and  stricture  and  in  zones  of  granulation.  Caution  concerning  the 
pressure  of  tube  or  fluid  in  producing  such  appearance  must  ever  be  in 


044  URETHROSCOPY 

mind  and  vessel  chanjies  sliould  be  patiently  traced  to  their  cause  for 
diag;nosis.  Absence  of  bloodvessels  is  ahvays  seen  where  scar  tissue, 
as  in  fibrous  tissue,  has  obliterated  them. 

Elasiicift/. — Infiltration  of  the  mucosa  with  small  round  cells  of  the 
acute  infiammation  later  changes  to  connective-tissue  cells  in  the 
chronic  processes,  and  thus  are  respectively  constituted  the  soft  infil- 
tration or  edema  and  the  hard  infiltration  or  stricture.  All  dej];rees 
from  the  soft  lesions  of  subacute  urethritis  to  the  moderately  firm  and 
fixed  stricture  and  the  very  dense  scar  with  chan<^es  in  the  jjlands  and 
vessels  are  seen.  All  are  recognized  by  the  sluggish  collapse  of  the 
urethra,  the  reduced  or  absent  folds,  altered  apex  of  cone,  pale  and 
rather  nonvascular  walls,  enlarged  crypts  and  failure  to  respond  readily 
to  dilatation.  The  more  active  lesions  are  cephalad  to  the  zone  of 
inelasticity. 

Crypts,  Ghuids  and  Lacunoo. — As  these  details  are  all  different 
developments  of  gland  they  have  much  the  same  processes  in  kind  and 
degree.  The  lacunae  of  INIorgagni  are  the  largest  and  the  most  distinctly 
glandular.  Oberlaender^  regards  chronic  urethritis  as  of  two  forms: 
soft  infiltration  and  hard  infiltration,  and  further  subdixides  the  degree 
of  glandular  changes  into  two :  Degree  I  is  folliculitis  without  retention, 
in  which  the  ducts  are  patent  and  the  secretion  discharged,  and  Degree 
II  is  folliculitis  with  retention  in  which  the  ducts  are  occluded  and  the 
secretion  retained.  In  early  hard  infiltration  and  glandular  disease 
without  retention  the  glands  are  discrete  or  grouped,  enlarged  and 
infiamed,  but  the  inflammation  is  relatively  slight  and  not  around 
the  ducts,  otherwise  they  would  be  occluded.  The  secretion  from  the 
glands  causes  the  moisture  and  the  shreds.  If  the  glands  are  occluded 
and  their  secretion  retained  the  hard  infiltration  is  around  the  ducts, 
the  secretion  cannot  escape  but  goes  on  to  form  cysts,  appearing  as 
beadlets  along  the  mucosa.  Atrophy  of  the  gland  commonly  follows 
and  the  whole  process  is  dry. 

In  more  adx'anced  hard  infiltration  and  glandular  disease,  without 
retention  the  grouping,  enlargement,  inflammation  and  infiltration  are 
all  more  marked  but  the  ducts  are  still  patent,  red  and  conspicuous. 
Moisture  and  discharge  are  still  present  but  thicker.  In  glandular 
disease  with  retention  the  infiltration  is  still  further  advanced  and 
obvious.  The  ducts  are  densely  closed,  the  glands  atrophied  and  scars 
rather  than  cysts  represent  their  positions.  There  is  no  secretion  and 
therefo'-e  no  discharge. 

La.ritij  and  Folds.— Changes  in  these  details  follow  those  of  thickness 
and  elasticity  and  are  virtually  manifestations  of  both.  Both  decrease 
as  cellular  substitutions  supervene.  In  fact,  it  is  the  alteration  in  the 
laxity  and  the  folds  which  designates  those  in  the  thickness  and 
elasticity. 

Gloss. — The  normal  luster  is  pronounced  from  the  smoothness  of  the 
epithelium,  the  moisture  and  the  vascularity  of  the  membrane.    Exfolia- 

'  Die  chronische  Gonorrhoe  der  miinulichc  Harnrohre,  1910,  ii,  p.  110. 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  CAo 

tion,  granulation  and  ulceration  show  a  loss  of  gloss  through  varying 
degrees  of  destruction  of  the  epithelium,  and  each  has  its  characteristic 
raw  base  in  ascending  order  as  stated.  Hypertrophy  and  cellular  sub- 
stitution in  stricture  deprive  the  surface  of  luster  through  absence  of 
bloodvessels,  trophic  changes  and  alteration  in  color  from  a  yellow 
red  to  a  patchy-white.  Some  of  these  surfaces  look  granular  and 
roughened. 

In  a  previous  study  the  author^  has  reviewed  the  causes  of  chronic 
urethritis  from  their  anatomical  basis  in  the  following  terms: 

"The  causes  are  anatomic,  physiologic  and  pathologic.  The 
anatomic  causes  are  inherent  in  the  fact  that  the  various  portions  of  the 
urethra  more  or  less  tend  to  invite  infections  of  the  gonorrheal  type 
and  its  corollaries.  For  example,  we  know  that  the  prostatic  urethra 
is  normally  the  widest  part  of  the  urethra  in  diameter  and  is  bounded 
behind  by  the  sphincter  and  in  front  by  the  verumontanum.  In  this 
pouchlike  cavity,  therefore,  the  gonorrheal  pus  may  lurk,  and  there 
set  up  those  changes  in  the  mucous  membrane  that  are  seen  everywhere 
in  other  mucous  membranes  as  the  signs  of  persistent  inflammation. 

"Passing  forward  to  the  verumontanum  and  the  right  and  left 
prostatic  sinuses  on  each  side  of  it,  we  again  find  a  complex  anatomic 
arrangement,  in  which  the  inflammation  may  very  easily  reside  and 
from  which  it  is  not  easy  to  drive  it.  The  posterior  extremities  of  the 
prostatic  sinuses,  called  the  prostatic  fossettes,  may  be  so  shallow  that 
they  are  difficult  to  recognize,  as  offset  from  the  floor  of  the  urethra  on 
either  side  of  the  crest;  or  they  may  be  so  deep  as  to  be  difficult  to 
illuminate  and  inspect  with  the  urethroscope.  This  form  of  prostatic 
sinus  usually  has  its  floor  thrown  into  folds,  which  only  complicate  the 
difficulty. 

"  Where  the  verumontanum  rests  against  the  lateral  prostatic  lobes, 
the  sinuses  are  long,  narrow  and  relatively  deep,  and  invite  the  forma- 
tion of  granulations  therein,  with  or  without  papillomata. 

"The  fact  that  in  these  special  parts  of  the  urethral  tract  the  walls 
are  in  apposition,  much  more  closely  indeed  than  are  the  walls  of  the 
urethra  itself  as  a  whole,  tends  to  invite  and  augment  those  changes 
in  the  mucous  membrane  which  the  disease  produces  only  too  actively, 
even  where  there  is  no  such  close  contact.  If  one  may  draw  an  analogy 
of  this  condition,  it  would  be  the  persistence  with  which  the  victims  of 
eczema  suffer  from  eczema  intertrigo  wherever  the  skin  makes  an  angle, 
is  folded  upon  itself,  and  remains  more  or  less  in  contact,  as  behind 
the  ears  and  in  the  cavities  of  the  armpits,  elbow^s,  groins,  buttocks, 
knees  and  interdigital  spaces. 

"The  great  frequency  of  prostatic  ducts  along  these  walls  invites 
the  penetration  of  infection  therein  by  the  imprisoned  pus.  The  roof 
of  the  urethra  in  the  prostatic  region  frequently  possesses  a  number 
of  folds,  from  which  proceed  the  fact  that  cysts  of  the  roof  are  so 
common. 

1  New  York  Med.  Jour.,  October  19,  1912. 


G4G  URKTHROSCOPy 

"The  membranous  urethra  is  a  httle  less  apt  to  be  involved  on 
definite  anatomic  grounds.  The  bulb,  however,  which  is  the  next  im- 
portant part  of  the  urethra,  is  far  otherw'ise  in  its  anatomic  relations. 
It  may  be  a  slight  or  an  extensive  pouching  of  the  ordinary  passage. 
In  the  former  case,  lesions  of  its  Hoor  seem  to  be  relatively  infrequent. 
In  the  latter,  however,  one  not  uneonunonly  finds  an  interesting  variety 
of  conditions.  The  circular  fibers  of  the  urethra  about  the  bulb  are 
sometimes  seen  to  throw  the  floor  of  the  bulb  into  transverse  folds, 
precisely  like  a  miniature  of  the  bladder.  The  mucous  membrane  as  a 
whole  may  be  rough,  shaggy,  or  the  mucous  cr,^'])ts  may  be  infected. 
Ulcers  and  strictures,  strictly  as  such,  are  sometimes  seen  at  this  part. 

"  In  the  anterior  urethra,  the  normal  arrangement  is  the  presence  of 
nimierous  mucous  follicles  along  the  dorsum,  any  one  or  few  of  which 
may  become  involved  and  go  on  indefinitely  to  chronic  suppuration. 

"Most  anatomists  assert  that  the  anterior  urethra  has  normally 
large  mucous  crN'i)ts,  whose  mouths  are  visible  to  the  naked  eye  in  the 
adult.  It  would  be  interesting  to  make  a  study  of  this  fact,  because  I 
have  recently  urethroscoped  one  adult  w^ho  never  had  had  venereal 
disease,  whose  urethra  show'ed  at  no  point  an  enlarged  mucous  follicle, 
excepting  the  lacuna  magna.  He  w-as  subjected  to  this  examination 
for  its  moral  effect  upon  his  neurasthenia,  which  had  a  sexual  basis. 
It  is  a  well-known  fact,  however,  that  mucous  crypts  are  not  only  of 
simple,  but  also  of  complex  tj^pes,  so  that  they  do  not  only  constitute 
little  cuplike  depressions,  but  may  pass  along  under  the  mucous  mem- 
brane, so  as  to  form  more  or  less  angulated  cavities.  In  such  cavities 
as  these  cr;^-pts  then  form,  the  gonococcus  may  abide  for  life  and  defy 
all  hiunan  skill  in  eradicating  it. 

"  Last  and  not  least  is  the  anatomic  fact  that  the  urethra  at  rest  is  a 
closed,  collapsed  tube  with  walls  in  apposition,  which  only  tends  to 
imprison  discharge  somew'hat  and  grant  the  gonococcus  still  more 
opportunity  to  penetrate. 

"The  physiologic  causes  of  the  chronicity  and  persistency  of  gonor- 
rhea embrace  the  two  features  of  the  normal  activities  of  the  various 
glands  throughout  the  urethra,  and  the  normal  sexual  activity  of  the 
various  organs  comprising  the  general  external  genitals.  Thus  it  is 
that  irritation  and  hypersensitiveness  w^hich  accompany  chronic 
involvement  in  a  more  or  less  degree  tend  to  stimulate  the  sexual 
activities.  This  disturbance,  in  turn,  inclines  to  invite  penetration 
and  prolongation  of  the  trouble. 

"The  pathologic  causes  rest  particularly  in  the  nature  of  the  gono- 
coccus and  those  germs  which  frequently  accompany  the  gonococcus 
and  penetrate  into  the  deeper  regions  of  any  portion  of  the  body  surface 
attacked.  Therefore,  w'hen  the  anatomic  and  physiologic  conditions 
have  played  their  part,  w'e  find  the  disease  has  penetrated  into  the 
mucous  follicles,  the  prostatic  ducts,  the  seminal  ducts,  and  the  outlets 
of  Cowper's  glands  (to  say  nothing  of  the  seminal  vesicles,  vasa  defer- 
entia,  testes,  etc.),  from  which  it  is  extremely  difficult  to  eradicate  it. 

"The  pathology  of  chronic  mucous  membrane  inflammation  is  well 


URETHROSCOPY  OF  THE  NORMAL  (I  RET  f I  HA.  047 

known  and  differs  in  no  degree  or  detail  in  the  male  urethra  froru  Ifie 
pathology  of  every  other  mucous  membrane,  in  male  or  female,  in  child 
or  adult,  namely,  thickening  of  the  mucous  membrane  as  a  whole, 
cystic  degeneration,  involvement  and  obliteration  of  the  mucous  crypts, 
unhealthy  granulation  tissue,  in  spots  or  more  or  less  disseminated. 
Where  folds  occur,  these  granulations  go  on  to  the  formation  of  warts, 
which  act  as  foreign  bodies  and  produce  a  chronic  discharge,  germ- 
bearing  or  not,  as  each  case  develops,  and  not  infrequently  to  the  causa- 
tion of  symptoms  of  stricture." 


Special  Features  of  the  Pathologic  Urethral  Segments. 

Complete  Urethroscopy. — As  noted  under  this  subject  in  the  normal 
urethra  the  work  must  be  begun  within  the  bladder  and  terminate  at 
the  meatus.  Under  the  subject  of  indications  it  is  shown  that  every 
chronic  urethritis  should  receive  a  urethroscopy,  because  lesions  may 
exist  at  any  point  and  demand  treatment,  although  they  may  give  no 
focal  symptoms  of  importance.  Lesions  of  the  mucosa  are  known  to 
occur  notwithstanding  negative  results  of  a  physical  examination,  with 
urethral  instruments,  rectal  touch  and  laboratory  examination.  The 
urethroscope  is  the  one  instrument  which  will  reveal  exact  conditions, 
and  it  should  be  used  as  faithfully  as  other  modern  electrically  illumi- 
nated diagnostic  instruments,  such  as  the  ophthalmoscope,  laryngo- 
scope, rhinoscope,  auroscope  and  the  like.  The  rule  is  therefore  safe 
that  a  urethroscopy  should  be  done  even  when  the  prostate  gland  as 
a  secreting  organ  seems  normal  and  when  a  multiple-glass  test,  such 
as  the  seven-glass  test  of  the  author,  gives  no  positive  findings.  Even 
indefinite  subjective  symptoms  will  proceed  from  a  damaged 
mucosa. 

In  short,  a  competent  and  complete  urethroscopy  is  the  final  step 
in  diagnosis  in  all  cases  of  chronic  urethral  lesions.  It  is  already  well 
known  that  acute  urethritis  contraindicates  it,  likewise  acute  exacer- 
bations of  complications. 

Vesical  Neck.  —  Urethroscopic  Picture. — This  transitional  point 
between  the  bladder  and  the  urethra  is  an  index  of  the  condition  of  the 
bladder  itself.  The  same  general  signs  of  chronic  inflammation  are 
seen  in  its  mucosa  as  in  other  mucosse  and  the  discovery  of  such  by  the 
urethroscope  indicates  a  cystoscopy. 

Under  cystocopy  are  shown  all  the  clinical,  diagnostic  and  therapeutic 
data  so  that  these  need  not  be  repeated  here. 

Posterior  Urethra. — Common  Lesions. — ^^Vithin  the  prostatic  urethra 
the  following  signs  of  chronic  inflammation  are  seen  and  will  be  dis- 
cussed in  the  order  given:  soft  infiltrations,  bullous  edema,  infected 
glands,  gaping  ducts,  thick  discharge  from  crj-pts  and  prostatic  ducts, 
granulations,  polypoid  masses,  exfoliations,  ulcers,  deformities  and 
stricture. 


648 


URETHROSCOPY 


Fig.  154  Fig.  155 

Figs.  154-161. — Urethroscopic  fields  of  the  male  urethra.     (Wiehe-Chemuitz.') 
Fig.  154. — Middle  part  of  the  pendulous  normal  urethra  with  strongly  outlined  blood- 
vessels and  closure  of  the  lumen  at  the  center.     Normal  gloss  of  epithelium  present. 

Fig.  155. — Bulb  of  the  urethra  diu-ing  recent  inflammation;  instead  of  the  normal 
small  folds  there  appear  gross  swellings  or  edema,  absence  of  bloodvessels  and  of  gloss  of 
epithelium  around  the  central  lumen  which  is  patent. 


Fig.  156  Fig.  157 

Fig.  156. — Middle  of  the  pendulous  urethra.  On  the  surface  of  the  mucosa  extensive 
gross  inflammatorj'  changes  are  not  visible;  bloodve.s.sels  are  apparent  and  gloss  nearly 
normal  but  on  withdrawing  the  tube  a  small  drop  of  pus  is  expressed  from  the  infiltrated 
cavity  of  a  crj'pt  of  Morgagni.  At  the  top  of  the  figure  is  a  patent  but  pu-s-free  crypt. 
The  central  lumen  is  closed  by  small  lobules  .somewhat  as  in  Fig.  155,  suggesting 
infiltration. 

Fig.  157. — Soft  infiltration  in  the  posterior  portion  of  the  pendulous  urethra,  with 
succulent  mucosa  and  irregular  swelling;  bloodvessels  are  imperfectly  visible  and  gloss 
altered.    In  the  upper  part  of  the  field  is  a  cyst  of  a  urethral  follicle. 


'  Wichc-Chemnitz  in  Oberlaender-KoUman,  Die  Chronische   Gonorrhcc   der    miinn- 
lichen  Harnrohre,  2d  ed. 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  f)49 


Fig.  158  Fig.  159 

Fig.  158. — Middle  part  of  the  pendulous  urethra  healed  after  prolonged  mechanical 
treatment.  As  final  remnant  of  the  cured  gonococcal  infection  on  the  right  is  seen  a 
white  area  (soft  scar  of  Oberlaender)  and  a  definite  decrease  in  folds.  The  central  lumen 
consists  of  a  slit  with  four  large  folds  leading  into  it.  A  crypt  of  Morgagni  is  patent  in 
the  upper  part  of  the  field.     Bloodvessels  and  gloss  are  less  distinct  than  normal. 

Fig.  159. — Bulb  of  the  urethra  in  a  dense  stricture.  A  dirty  gray  discoloration  of  the 
mucous  membrane  with  only  few  bloodvessels  and  no  gloss  is  apparent.  The  lumen  is 
a  transverse  sHt  with  deep  large  furrows  leading  into  it. 


Fig.  160  -  Fig.  161 

Fig.  160. — Middle  of  the  pendulous  urethra.  A  very  dense  stricture  holds  the  lumen 
of  the  canal  open  as  a  rigid  tube  vnth.  a  tunnel-like  chink.  As  the  result  of  progressive 
dilatation  new  bloodvessels  are  seen  in  the  process  of  formation.  Above  on  the  left  is  a 
patent  crypt  of  Morgagni.  Normal  gloss  of  the  epithehum  is  replaced  by  pallor  of  the 
scar. 

Fig.  161. — Entrance  into  a  stricture  in  the  pendulous  urethra.  The  central  fieure 
is  seen  as  a  transverse  sUt  without  ob\'ious  folds  and  the  mucosa  is  altered  as  to  gloss  and 
bloodvessels. 


650 


URETHROSCOPY 


0^ 


Fu;.    1G2. — Floor  of  the  sphincter  and  sviprainoiitane  urethra.      (Buerger.') 


Fig.  1G3. — Xormal  type  of  coUiculus 
(verumontanum),  with  h\rge  utricle. 
(Buerger.) 


Fig.  1G4. — Normal  coUiculus,  showing 
three  vertical  slits,  the  utricle  in  the 
center  and  the  ejaculatory  ducts  on 
either  side.     (Buerger.) 


Fig.  165. — Normal  ciilliculus,  showing 
the  utricle,  the  ejaculatory  ducts,  the  de- 
clive  above,,  and  the  posterior  frenula. 
(Buerger.) 


Fig.  1G6. — Junction  of  the  bulbous 
and  pendulous  urethra;  the  bulb  is  not 
properly  Uluminated.     (Buerger.) 


Fig.  167. 


-Right  margin  of  the  sphincter. 
(Buerger.) 


Fig.  168. — Cystic  changes  at  the  right 
margin  of  the  sphincter.  (Buerger.) 


'  Cabot's  Modern  Urology,  1918,  pp.  98-103. 


URETHROSCOPY  OF  TIIIC  NORMAL  (JRETIIRA 


651 


Soft  Infiltrations. — Chiefly  along  the  roof,  less  at  the  sides  and  rarely 
on  the  floor  of  the  posterior  urethra,  are  seen  grape-like  swellings,  often 
called  bullous  edema.  They  are  large  or  small,  few  or  many,  scattered 
and  discrete,  grouped  and  confluent,  usually  nonvascular  and  pale, 
occasionally  vascular  and  red,  soft,  easily  hemorrhagic  and  disappear 


Fig.  169. — Cystic    changes   in   the    veru- 
montanum.     (Buerger.) 


Fig.  170. — Atrophy  of  the  verumon- 
tanum  with  crater  formation  due  to 
rupture   of   an   abscess.     (Buerger.) 


Fig.  171. — A  deep  scar  and  large  crypt 
in  the  right  sulcus  lateralis  and  distortion 
of  the  colliculus.     (Buerger.) 


Fig.  172. — Floor  of  the  sphincter  in 
so-called  lateral  lobe  hypertrophy  (pros- 
tatic adenoma).     (Buerger.) 


Fig.  173. — Lateral  lobe  hypertrophy  in 
the  supramontane  region  viewed  with  the 
cysto-urethroscope.     (Buerger.) 


Fig.  174. — Lateral  lobe  hypertrophy: 
view  just  above  the  venimontanum ;  the 
latter  is  small.     (Buerger.) 


on  pricking  with  knife  or  other  instrument.  They  do  not  seem  to  be 
followed  by  important  sequels  and  may  be  regarded  as  a  low-grade 
edema  expressive  of  chronic  inflammation.  They  are  probably  lesions 
greatly  benefited  by  the  pressure  of  sounds  and  dilators. 

Treatment. — Soft  infiltrations  often  terminate  under  good  manage- 
ment and  treatment  without  urethroscopic  methods  other  than  that 


652  URETHROSCOPY 

for  filial  (liaiinosis.  The  iiiflaiiiniatory  character  of  the  focus  indicates 
sedation  rather  than  stiniuhition,  hence  urethrosco})ic  activity  is  not 
advisable.  Dilatation  with  any  instrument  should  be  carefully  under- 
taken and  flexible  sounds  are  preferred.  No  reaction  should  follow 
such  steps.  If  indolent  granulations  and  infiannnation  characterize  the 
annexa  of  the  infiltration  they  may  be  reg  irded  as  more  or  less  the 
cause  of  it  and  must  be  cured  before  the  infiltration  will  be  relieved. 
Cure  is  fully  discussed  in  the  clinical  sections. 

Bullous  Edema. — The  urethroscope  is  not  a  satisfactory  instrument 
for  treating  bullous  edema  because  it  is  too  irritable  and  iiiHammatory, 
so  that  much  the  same  principles  api)ly  as  for  soft  infiltration.  The 
cause  of  the  edema  should  be  sought  and  treated  in  order  to  benefit 
the  edema.  Puncture  of  the  cystlike  masses  and  stripping  them  with 
the  weak  Oudin  current  or  with  mild  chemical  caustics  have  little 
merit,  as  in  most  cases  the  lesions  are  repeated  in  a  higher  degree. 
Underlying  protV)und  inflammation  as  seen  in  i)rostatitis  and  tuber- 
culosis must  be  controlled  in  order  to  influence  the  bullae.  This  lesion 
is,  therefore,  rather  a  symptom  than  a  distinct  entity.  Gentle  dilata- 
tion with  sounds  or  expanding  dilators  will  often  help,  combined  with 
relief  of  the  underlying  cause.  Cure  is  fully  detailed  in  the  clinical 
sections. 

Chronic  Infected  Glands  and  Gaping  Ducts. — The  glands  are  the 
mucous  follicles  scattered  over  the  roof  of  the  prostatic  urethra  and 
may  be  scattered  and  few  or  grouped  and  numerous.  Dependent  on 
the  activity  of  the  process  they  may  be  red  points  with  a  zone  of  redness, 
or  open  pockets  filled  with  or  discharging  globules  of  mucopus  and  have 
definite  depth.  They  may  project  above  the  surface  similar  to  acne 
phnples.  As  elsewhere  in  the  canal  such  glands  are  simple  or  com- 
pound and  become  of  great  importance  in  maintaining  infection. 
AYhile  present  in  the  prostatic  urethra  they  are  much  less  numerous 
than  in  the  anterior  urethra,  where  they  are  a  very  common  lesion. 

The  gaping  ducts  are  open  mouths  of  ducts  and  chiefly  those  of  the 
prostatic  acini.  All  degrees  of  visibility  are  seen  from  just  apparent 
to  8  to  10  F  in  diameter.  Where  abscess  of  an  acinus  has  occurred  a 
wide-open  cavity  may  appear.  The  largest  ducts  are  in  the  prostatic 
sinuses.  The  edges  are  smooth  or  ragged,  pale  or  red;  the  contents  are 
fluid  or  form  pus,  all  according  to  the  activity  of  the  process.  The 
de])th  as  a  rule  is  not  great  .but  definitely  more  than  that  of  mucous 
follicles.  These  are  permanent  lesions  and  do  not  recover  except  by 
operative  obliteration. 

Treatment. — The  indication  is  to  eradicate  the  pocket  and  sinus 
formed  by  the  gland  and  its  duct.  For  this  purpose  the  urethroscope 
is  extremely  valuable  in  the  anterior  and  the  posterior  urethrse  by 
means  of  applications,  incisions  and  cauterizations. 

In  general,  applications  are  of  little  value  except  after  the  other  two 
methods  have  been  applied,  because  the  caustics  strong  enough  to 
destroy  the  focus  flood  the  mucosa  of  the  annexa  more  than  they 
penetrate  the  duct  of  the  gland.    This  leads  to  unnecessary  damage. 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  653 

The  incision  technic  requires  exposure  of  the  gland  in  the  fenestrum 
of  the  urethroscope  followed  by  local  anesthesia  with  cocain  or  its 
derivatives  and  bv  hemostasis  with  adrenalin  or  a  chemical  styptic. 
Rather  free  stabbing  or  incision  of  the  duct  and  gland  to  lay  them 
open  from  the  bottom  is  then  done.  Blood  and  pus  are  swabbed  away 
and  the  wound  cauterized  with  a  chemical  caustic,  electrocautery  or 
the  high-frequency  current  of  Oudin.  The  last  two  are  much  preferred 
because  controlled  in  placing  the  points  while  cold  and  then  in  turning 
on  the  current  limited  by  the  rheostat  in  its  activity  to  meet  the 
requirement  of  the  disease. 

The  direct  cauterization  without  cutting  is  best  performed  by  the 
current  of  Oudin,  whose  strength  is  made  coagulating  for  the  severe 
cases  and  desiccating  for  the  milder  cases  and  never  incinerating  for  any 
case.  The  soap  test  described  on  page  501  should  be  employed  as  the 
measure  of  current.  The  electric  wire  with  its  tip  projecting  a  little 
beyond  the  insulation  is  applied  to  the  duct  and  if  possible  penetrates 
it,  and  then  the  current  is  turned  on  and  off  for  brief  intervals  several 
times  until  mild  coagulation  is  seen.  If  w^ell  done  a  superficial  scar 
is  produced,  invisible  as  soon  as  the  reaction  disappears.  Such  scar 
does  not  involve  the  submucosa  or  deform  the  canal.  In  Skene's  glands 
the  urethroscope  is  usually  unnecessary.  Any  of  the  foregoing  methods 
might  be  applied  to  them  but  would  be  more  difficult  than  the  technic 
already  given  for  the  surgical  treatment  of  these  glands  under  compli- 
cations in  the  female. 

In  the  aftertreatment  granulations  and  similar  lesions  located  near 
the  diseased  glands  are  treated.  A  hand  injection  of  any  astringent, 
such  as  argyrol,  5  to  10  per  cent.,  or  the  Ultzmann  solution,  will  abate 
any  tendency  to  catarrhal  sequels.  The  little  slough  is  usually  cast 
in  from  five  to  seven  days  and  then  its  base  must  be  touched  with 
nitrate  of  silver,  10  per  cent,  to  25  per  cent.,  without  flooding  the 
annexa. 

Cure  is  clearly  outlined  in  the  clinical  paragraphs  on  this  subject. 

Thick  Discharge. — Pus  is  seen  on  the  surface  and  in  the  cr^'pts  and 
acini.  It  may  be  removed  by  gentle  massage  or  sometimes  with  the 
platinum  loop  from  the  glands  and  ducts  and  mopped  from  the  surface 
with  swabs.  It  is  often  adherent  and  wipes  or  washes  away  with  real 
difliiculty,  revealing  beneath  exfoliation,  ulceration,  diseased  glands 
and  granulations.  It  contains  organisms,  epithelial  cells  and  detritus, 
but  is  sometimes  sterile  to  smear  and  culture;  it  may  be  regarded  as  a 
temporary  lesion  and  disappears  when  its  source  is  removed. 

Treatment. — The  two  origins  of  thick  discharge  must  be  respected, 
which  are  endourethral,  proceeding  from  the  glands,  and  exourethral, 
developing  in  the  prostate  and  the  glands  of  Cowper.  The  latter  has 
special  treatment  not  concerned  with  urethroscopy,  which  has  been 
detailed  under  gonococcal  lesions  of  the  prostate  and  glands  of  Cowper 
on  page  113.  The  urethroscope  will  locate  the  endourethral  cases 
in  lesions  such  as  diseased  glands,  stricture,  granulations,  ulcers  and 
neoplasms  and  until  such  foci  are  relieved  much  of  the  discharge  will 


654  URETHROSCOPY 

continue.  In  the  afteitreatnient,  however,  of  the  foci  urethroscopy 
with  special  appHcations  will  decrease  and  finally  will  relieve  the 
exudate.    Cure  is  fully  noted  in  the  clinical  sections  of  this  book. 

Craniilatioiis. — When  the  chionic  diseise  has  broken  the  surface  of 
the  mucosa  hypertrophy  of  the  jxi'anulations  in  the  healing  ])rocess  may 
occur.  Onlinary  exuberant  granulations  are  conunon;  if  excessive 
a  granuloma  occurs  and  if  still  further  developed  a  polypoid  tendency 
or  a  polypus  is  seen.  All  are  therefore  a  development  of  the  healing 
process  in  granulations.  They  are  apt  to  ai)i)ear  in  the  folds  of  the 
mucosa,  and  in  this  respect  resemble  eczema  in  its  i)redilection  for  the 
folds  and  angles  of  the  skin.  They  therefore  are  chiefly  in  the  prostatic 
sinuses,  around  the  base  of  the  coUiculus  where  it  presses  into  the  roof 
of  the  canal.  They  appear  as  rough  or  fine  outgrowths  or  very  uneven 
projections  of  the  surface  or  even  sessile  poly])oid  masses.  Being 
highly  vascular  they  bleed  easily  and  obstinately.  The  minor  degrees 
are  temporary  lesions  and  easily  cured  with  treatment,  but  the  major 
degrees  are  much  more  severe  and  may  lead  to  strictiu'e. 

Treaiment. — The  urethroscope  reaches  these  lesions  better  than  any 
other  method.  A])plications  are  made  as  on  similar  conditions  on  the 
surface  of  the  body.  There  must  be  superficial  reduction  in  most  cases 
and  occasionally  relatively  deep  destruction,  but  always  with  caution. 
The  curette  is  good  if  it  may  be  readily  and  exactly  applied,  but  in  the 
author's  opinion  several  applications  of  the  weak  current  of  Oudin  in 
the  desiccating  strength  are  the  best  treatment  and  may  be  repeated 
eN'ery  five  to  seven  or  ten  days  as  needed.  Around  such  granulations 
are  nearly  always  found  unhealthy  glands  which  must  be  treated  in 
the  manner  already  noted,  after  the  granulations  have  been  removed. 
Cure  is  described  in  the  clinical  sections  of  this  volume. 

Poh/poid  Masses. — These  are  the  later  stages  of  granuloma  and  are 
sometimes  wrongly  called  papillomata.  True  papilloma  of  the  urethra 
is  a  very  raie  occurrence  but  polypi  are  very  common  and  have  their 
origin  in  unhealthy  granulations.  They  are  usually  sessile,  much  less 
commonly  pedunculated  and  apt  to  appear  on  or  about  the  colliculus, 
often  caudad  but  less  frequently  cephalad  to  it.  They  may  be  as  large 
or  larger  than  the  colliculus  and  difficult  to  distinguish  from  it.  Their 
origin  seems  to  be  irritation  from  the  pus  and  mucopus  more  or  less 
retained  in  the  folds  of  the  canal  and  stimulating  exfoliations  to  such 
outgrowths.  Such  pus  is  commonly  not  sterile  although  it  may  not 
contain  the  gonococcus.  The  lesions  are  permanent  unless  relieved  by 
treatment. 

Treatment. — Again  the  urethroscope  is  the  most  certain  and  ready 
means  of  treatment.  Liquid  caustics  are  almost  useless  because  they 
reach  healthy  tissue  near  the  growths  and  do  harm.  Many  of  the 
pohpi  may  be  removed  with  snare  or  scissors,  but  the  afterbleeding  is 
a  disadvantage.  In  the  author's  experience  the  high-frequency  current 
of  Oudin  to  the  coagulating  degree,  as  shown  by  the  soap  test  described 
on  page  oOl,  is  the  most  exact  and  satisfactory  means.  One  or  a 
few  applications  about  one  week  apart  are  commonly  enough.     The 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  655 

direct  d'Arsonval  current  is  favored  by  some  authorities  and  applied 
in  strength  of  150  to  300  milliamperes.  Any  unhealthy  glands  or 
mucosa  around  the  base  must  be  treated  after  the  growth  is  removed 
and  the  wound  healed.  Cure  may  be  dismissed  with  the  clinical  details 
previously  given. 

Exfoliations. — Denuded  spots,  patches  and  zones  due  to  the  activity 
of  the  acute  process  and  continued  by  the  chronic  disease  are  shown  by 
the  absence  of  luster,  roughness  of  base  and  overhanging  edges.  Such 
edges  are  often  free  and  wave  in  the  irrigating  fluid.  Ulceration  is  a 
later  stage.  Exfoliations  are  usually  temporary  and  heal  under  proper 
treatment,  but  they  often  go  on  to  ulceration. 

Treatment. — The  loss  of  superficial  epithelia  is  the  early  stage  of  ulcer 
without  infection  and  is  readily  seen  with  the  urethroscope.  Mild 
applications  on  swabs  of  silver  nitiate,  from  1  per  cent,  to  10  per  cent., 
tincture  of  iodin  and  even  95  per  cent,  alcohol — all  without  flooding — 
are  readily  curative.  The  aftertreatment  may  require  attention  to 
diseased  glands  which  may  be  in  the  same  portion  of  the  canal.  Cure 
is  discussed  in  the  Clinical  sections. 

Ulcers. — Open  sores  are  the  later  progress  of  exfoliation  by  deepening 
and  extending  the  process.  Superficial  or  deep  abscesses  rupture  and 
leave  excavated  ulcers.  The  picture  is  a  sore  of  various  irritability, 
superficial  or  deep,  large  or  small,  and  with  edges  undermined  and 
ragged  and  base  rough  and  raw.  Pus  may  cling  to  its  surface  or  extrude 
from  its  cavity.  Bleeding  often  follows  removal  of  the  exudate  wath 
swabs,  instruments  or  water.  In  the  termination  the  ulcers  heal,  causing 
various  deformities  which  twist  the  lumen  out  of  size  and  shape,  but 
in  the  prostatic  urethra  rarely  close  the  canal  because  this  segment  is 
normally  the  largest  and  supported  by  the  firm  substance  of  the  prostate. 

Treatment. — Open  sores  of  the  mucosa  may  be  irritated  and  extended 
by  passing  the  urethroscope,  and  hence  the  need  of  added  gentleness, 
anesthesia  and  styptics.  According  to  their  condition  the  treatment  is 
exactly  like  that  of  granulations  but  more  energetic.  Liquid  caustics 
must  be  exactly  applied  and  not  flooded  on  the  mucosa  and  the  slough 
of.  such  reductions  may  be  removed  with  the  curette  gently  if  it  is  not 
shed  in  about  a  week.  As  a  rule  it  is  better  not  to  curette  them.  The 
writer  believes  that  the  most  exact  results  follow  the  use  of  the  current 
of  Oudin  in  the  desiccating  or  coagulating  strengths  every  seven  or  ten 
days  according  to  reaction.  Deep  destruction  is  rarely  necessary. 
The  aftertreatment  regards  the  chronic  inflammation  and  the  diseased 
glands  surrounding  the  ulcer  and  furnishing  other  evidence  of  profound 
infection.    Cure  is  fully  detailed  in  the  clinical  sections. 

Deformities. — As  already  indicated,  these  are  the  sequels  of  ulceration 
and  ruptured  abscess  in  their  healing  processes.  They  likewise  arise 
from  hard  infiltrations  which  in  the  anterior  urethra  would  lead  to 
closure.  These  deformities  are  really  strictures  in  the  sense  that  they 
are  deep  and  extensive  alterations  in  the  walls  of  the  canal,  depriving 
it  of  elasticity,  normal  moisture  and  full  lumen,  although  the  lumen 
itself  is  not  closed. 


656  URETHROSCOPY 

Treat nioit. — Great  clian^es  in  the  form,  ealiber  or  course  of  the 
urethra  are  hardly  amenable  to  the  urethroscope  beyond  the  important 
detail  of  exact  diagnosis.  Their  repair  belongs  to  plastic  surgery  in 
external  and  internal  urethrotomy.  IVIost  of  the  cases  are  due  to 
stricture,    ("ure  is  outlined  in  the  clinical  paragra])hs. 

^S7//c////v',s'.^These  are  hardened,  dry  areas  in  the  mucosa,  which  very 
rarely  extend  to  occlusion  of  the  passage..  Filiform  strictures  are  rarely 
seen  in  the  prostatic  urethra  on  account  of  its  anatomical  size  and 
arrangement.  The  ])athogenesis  of  stricture  is  fully  discussed  under 
this  Complication  of  Urethritis  on  page  33()  and  the  urethroscopic 
picture  is  described  under  Anterior  Urethra  on  i)age  641,  where  the 
lesion  is  more  typical. 

Treatment. — As  already  elucidated,  the  urethroscopic  diagnosis  reveals 
the  condition,  position,  type  and  Imnen  of  the  infiltration.  It  is  well 
to  decongest  deeply  the  entire  area  with  adrenalin  and  cocain  or  its 
derivatives.  The  liunen  is  in  this  manner  displayed  by  removing 
the  edema  of  inflammation  and  especially  that  of  faulty  attempts  at 
instrnmentation.  The  filiform  whalebone  guide  may  then  be  passed 
under  the  eye  and  then  dilating  sounds  employed,  by  choice  the 
author's  irrigating  type  of  instriunent,  because  the  bladder  may  be 
filled  with  fluid  which  flushes  the  urethra  from  end  to  end.  If  urethro- 
tomy is  selected  the  urethroscope  may  show  the  best  part  of  the  canal 
for  the  di^'ision  of  the  infiltration  whose  greatest  density  may  be  at 
any  point  and  usually  farthest  from  the  position  of  the  lumen — dorsal, 
lateral  or  ventral.  In  the  aftertreatment  the  granulations  and  chronic 
urethritis  proximal  to  the  stricture  must  be  relieved.  They  have  been 
described  in  the  paragraphs  on  stricture  of  Chapter  VI  on  pages  336 
to  343. 

False  Passage. — The  site,  course,  extent  and  nmnber  of  the  false 
passages  are  determined  by  the  urethroscope,  and  most  important  of 
all  their  relation  to  the  stricture.  After  this  has  been  proved  the 
urethroscope  is  a  guide  for  the  operative  treatment  of  the  stricture 
itself  and  then  of  the  false  passage.  Cure  of  both  stricture  and  false 
passage  is  fully  noted  in  the  clinical  section  in  Chapter  VII. 

Recapitulation.- — The  lesions  of  the  prostatic  urethra  are  usually  the 
most  im])ortant  for  the  urethroscopist.  According  to  the  location  and 
penetration  of  the  process  the  lesions  of  the  prostatic  urethra  seen  in 
the  urethroscope  may  be  simimed  up  as  follows:  The  whole  cavity  at 
any  point  of  the  surface  may  show  active  or  passive  hyperemia  or 
pallor,  thickening,  but  rarely  extending  to  occluding  stricture,  exfolia- 
tion, ulceration  and  edema.  Copious  exudate  may  bathe  its  walls  as 
fluid,  semifluid  or  formed  pus. 

The  glands  are  enlarged,  prominent  and  discharging,  or  enlarged, 
occluded,  cystic  or  atrophied.  Their  ducts  are  represented  by  puckered 
cicatricial  spots. 

The  colliculus  may  be  reddened  or  pale,  hypertrophied  or  atrophied, 
hemorrhagic  or  nearly  dry,  rough  or  smooth,  edematous  and  covered 
with  granulations  or  polypoid  growths. 


URETHROSCOPY  OF  THE  NORMAL  URETHRA  657 

The  utriculus  may  be  enlarged  and  deformed  jukI  filled  with  adherent 
exudate. 

The  prostatie  duets  and  ejaeulatory  duets  may  slunv  a  Jarge  variety 
of  changes  about  their  lips,  such  as  e version,  inversion,  closure,  patency 
and  altered  secretion.  The  ejaeulatory  ducts  correspond  in  their  con- 
dition with  that  of  the  utriculus  and  colliculus,  as  a  rule. 

Membranous  Urethra. — Chuif  Lesions. — The  urethros(;o[;ic  picture 
changes  from  the  general  complex  anatomy  of  the  posterior  urfithra 
to  the  more  simple  contents  of  the  anterior  urethra.  The  glands  are 
few  and  not  important.  The  processes  are  the  same  in  kind  as  in  other 
mucous  glands,  but  less  important  because  so  few  and  scattered.  Infil- 
tration of  the  mucosa  is  the  most  important  and  follows  the  kind  and 
degree  seen  in  the  anterior  urethra  and  especially  in  the  bulb  of  the 
same  individual.  It  is  for  this  cause  that  stricture  of  the  bulbomem- 
branous  juncture  becomes  important.  The  association  of  the  mem- 
branous urethra  with  the  pathology  of  the  bulb  is  the  reason  why  the 
latter  is  so  difficult  to  outline  in  the  urethroscope.  Except  stricture, 
the  lesions  of  the  membranous  urethra  are  not  severe  and  under 
appropriate  treatment  are  often  not  permanent. 

Anterior  Urethra. — Common  Lesions. — ^All  the  foci  of  disease  are  the 
same  as  in  the  prostatic  urethra  excepting  those  of  the  special  ana- 
tomical features  of  this  portion  of  the  canal,  such  as  the  colliculus  with 
its  utriculus  and  ejaeulatory  ducts,  the  prostatic  sinuses  with  their 
prostatic  ducts  and  the  crista  urethrae.  Conspicuous  in  the  anterior 
urethra  are  affections  of  the  lacunae  of  Morgagni,  glands  of  Littre  and 
soft  and  hard  infiltration.  All  the  former  have  been  thoroughly  dis- 
cussed for  the  posterior  m-ethra  and  the  general  pathologic  features  in 
urethroscopy  which  leaves  hard  infiltration  or  stricture  for  attention  here. 

Stricture. — The  author's^  classification  of  stricture  according  to 
diameter,  as  tight  from  filiform  to  10  F.,  as  close  from  10  to  20  F., 
and  as  open  from  20  F.  and  larger  is  convenient  but  arbitrary.  It  is  less 
objectionable  than  that  of  Oberlaender,^  who  seeks  to  limit  stricture  to 
those  changes  in  the  canal  which  refuse  23  F.  instrument.  The  urethro- 
scopic  picture  of  stricture  much  more  nearly  corresponds  with  the 
description  of  Finger^  and  show^s  glandular  disease,  periglandular 
extension,  submucous  involvement,  cellular  penetration  and  varying 
loss  of  elasticity  and  presence  of  deformity  of  the  canal.  It  may  not 
obstruct  the  lumen  greatly  but  it  means  destruction  and  atrophy  of 
the  mucosa  as  a  whole  at  that  point  or  zone  of  the  canal. 

As  shown  under  stenosis  as  a  complication  of  lu-ethritis  on  page  33-1, 
such  lesions  may  occur  at  any  point  of  the  canal  in  length  or  circmn- 
ference  and  in  depth  or  extension.  The  urethroscopic  picture  always 
supplements  and  proves  the  diagnosis  as  found  by  other  instriunents 
and  methods,  such  as  bougie-a-boule,  steel  or  flexible  sounds,  urethral 
palpation,  rectal  examination  and  the  seven-glass  test  of  the  author. 

The  color  is  pale,  bloodless  and  that  of  dense  scar-tissue.    The  vessels 

1  Loc.  cit.  -  In  Oberlaender  and  KoUmann,  Loc.  cit.,  p.  467  et  seq. 

'Blennorrbce  der  Sexorgane,  v,  1901. 
42 


65S  VRETIIIWSCOPY 

are  few  or  absent  and  no  sliit't  of  the  instrument  or  ehange  in  the 
dilating  air  or  tliiid  makes  them  appear.  Edema  is  t)ften  eephahid  to 
the  node  and  is  never  seen  on  its  sm-face  througli  absence  of  full  vascular 
sup])ly.  Inflamed  strictures  show  edema  in  all  annexa.  Elasticity  is 
irreatly  reduced  or  absent  and  this  forms  the  rieal  obstruction  to  the 
instrument.  It  is  ])ro\ed  by  absence  of  resiliency  to  the  air  or  fluid  and 
of  softness  to  the  touch.  The  crypts  are  usually  absent  entirely  or  a 
few  large  atrophic  and  dry  mouths  may  show  in  the  stricture  surface. 
nilatation,  gramilation  and  discharge  are  most  abundant  in  the  urethra 
for  an  inch  or  more  cci)halad  to  the  lesion. 

The  diagnostic  adxantages  of  the  mrthroscope  are  the  recognition 
of  location,  extent  and  variety  of  stricture,  the  irregularities  and  pecu- 
liarities of  its  kmien,  the  association  of  other  lesions,  such  as  chronic 
urethritis  and  the  proximal  dilatation  of  the  canal  with  granulomata, 
ulcerations  and  false  ])assages. 

FaL'ic  Pasmge. — The  general  clinical  factors  of  this  lesion  are  con- 
sidered as  a  part  of  stricture  in  the  Complications  of  L'rethritis  on  page 
409.  With  the  urethroscope  the  diagnosis  is  often  rendered  absolute 
in  a  way  that  fails  by  other  means.  Its  location  is  commonly  away 
from  the  maxinnun  density  of  the  stricture  node  and  often  in  relatively 
healthy  or  chronically  inflamed  urethral  wall  caudad  to  it.  Its  nature 
is  recognized  as  that  of  a  tear  varying  according  to  its  age.  Its  edges 
are  ragged  and  irregular,  hemorrhagic  or  not,  so  that  touch  with  the 
urethroscope  or  other  instrument  provokes  much  or  little  bleeding. 
Occasionally  with  the  operation  urethroscope  of  Buerger  or  McCarthy 
the  passage  may  be  entered  with  a  ureteral  catheter  or  the  air  dilata- 
tion urethroscope  of  ]\Iark  or  Elayden.  In  contrast  the  stricture  orifice 
is  in  the  substance  of  the  stenosis  and  is  usually  a  puckered  dry  opening 
if  \isible.  In  some  strictures  it  is  either  buried  in  ])roximal  edema  or 
very  difficult  to  see,  because  most  cases  of  false  passage  have  been 
repeatedly  traumatized  by  eft'orts  to  pass  the  obstruction  and  therefore 
show  much  edema  caudad  to  the  stricture. 

The  choice  of  urethroscope  in  diagnosticating  stricture  depends  on 
the  lumen  of  the  canal.  An  infiltration  which  passes  a  24  E.  instru- 
ment is  in  the  author's  opinion  best  studied  with  a  water-irrigating, 
lateral  fenestrum,  magnifying  urethroscope,  such  as  that  of  Buerger  or 
:\IcCarth>-.  If  the  stricture  is  close  (10  to  20  F.),  or  tight  (10  F. 
and  smaller),  then  the  air  dilatation,  terminal  fenestrimi,  magnifying 
urcthrosco])e  of  ]\Iark  or  Hayden  becomes  necessary.  There  is  no 
cjuestion  that  in  these  cases  the  terminal  fenestrum  instruments  give  a 
beautiful  picture  of  the  altered  wall  as  it  recedes  to  form  an  atypical 
cone.  These  facts  emphasize  the  author's  opinion,  as  already  stated, 
that  a  lu'ologist  should  have  both  types  of  modern  instrument. 

The  use  of  air  in  stricture  cases  with  false  passage  is  not  without 
danger  as  pointed  out  by  Fenwick,^  who  had  the  air  infiltrate  the 
perineum  during  the  examination  without  disastrous,  results,  although 
painful  to  the  patient. 

\  ^ustralasiao  NIed,  Gaz.,  1906,  xxv,  508, 


NONGONOCOCCAL  LESIONS  IN  UUETIIIilTIS  659 

B.     NONGONOCOCCAL  LESIONS  IN  URETHRITIS. 

Significance. — Many  of  tlie  ii()iifi;()ii()Coccal  rnanifcstatioDS  are  le.ss 
important  than  the  g(jnococeal  only  because  they  an;  rnu(;h  less  fre- 
quent, but  m  themselves  several  are  of  grave  meaning,  of  wliich  tuber- 
culosis is  a  familiar  example. 

Varieties. — The  general  classification  includes  anatomical  abnormali- 
ties, special  inflammations,  new  growths  and  foreign  bodies.  Under 
the  abnormalities  are  placed  valves  and  diverticula.  Special  inflam- 
mations embrace  catarrhal,  suppurative,  tuberculous,  herpetic,  chan- 
croidal, chancrous  and  cystic.  New  growths  are  benign  which  are 
exemplified  by  papillomata,  polypi,  fibroses  and  varices  or  malignant 
which  comprise  chiefly  carcinoma  and  sarcoma.  Foreign  bodies  are 
calculi  descending  from  the  kidneys,  ureters,  bladder  or  prostate. 

Anatomical  Abnormalties. — Valves!— halves  are  probably  in  nature 
overdevelopment  of  the  circular  muscular  bundles  of  the  urethra  or 
reduplications  and  redundancies  of  the  mucosa.  Taylor^  has  made  a 
cast  of  the  urethra  and  shown  at  least  eleven  normally  present  trans- 
verse muscular  bands.  Other  valves  are  probably  abnormally  large 
or  altered  lacunae  of  Morgagni  creating  folds  in  the  mucosa. 

In  locations  the  valves  may  be  seen  at  almost  any  point  of  the  urethra, 
but  most  commonly  in  the  anterior  portion.  They  may  also  be  on  any 
aspect  of  the  canal,  but  the  usual  site  is  the  roof,  where  the  support 
of  the  corpora  cavernosa  makes  the  valve  action  more  positive.  Simple 
reduplications  of  the  mucosa  are  seen  on  the  floor. 

In  size  the  valves  vary  from  small  to  large  with  a  tendency  to  definite 
dimensions  so  as  to  catch  instruments  in  exploratory  diagnosis  and  to 
accept  the  filiform  guide  or  the  ureteral  catheter  in  urethroscopy  to 
measure  its  depth.  It  is  probable  that  the  catching  of  the  filiform  guide 
in  the  dilatation  of  stricture  is  due  to  such  valves.  In  a  restricted 
sense  they  are  not  unlike  the  valves  of  Houston  in  the  rectum.  Their 
cavities  are  usually  directed  cephalad  and  their  openings  caudad. 
This  arrangement  is  rarely  reversed. 

The  urethroscopic  picture  is  that  of  a  narrowed  U  or  V  according 
to  the  patency  of  the  opening,  which  as  stated  is  toward  the  observer 
in  most  cases.  If  uninfected  the  lips  are  clean  and  tense  rather  than 
flaccid.  The  depth  varies  from  sufficient  to  catch  the  mere  point  of  an 
instrument  to  0.5  to  1.0  cm.  The  base  is  clean  and  may  show  one  or 
more  mucous  crypts.  If  infected  the  lips  are  thick  and  ragged  and  the 
floor  granular  and  bathed  with  pus  or  mucopus  which  may  be  wiped 
or  massaged  away.  External  pressure  on  the  urethra  may  extrude 
secretion.  Such  formations  are  definite  in  maldevelopment  or  path- 
ology of  the  lacunse,  but  much  less  so  in  the  muscular  valve  or  mem- 
branous reduplications. 

The  recognition  of  the  valves  is  by  exploration  with  the  filiform  or 
catheter  or  by  alterations  in  appearance  through  water  or  air  dilatation. 

1  Geni to-urinary  and  Venereal  Diseases,  3d  ed.,  p.  203. 


660  URETHROSCOPY 

The  easiest  valves  to  invest ipite  are  those  oiXMiing  eaiuhid.  into  whicli 
instriunents  and  diUitation  media  will  pass  readily.  Mark'  reports  a 
case  in  which  a  valve  opened  cephalad  in  the  bnlbons  eul-de-sac  in  a 
yoiniij  man,  twenty-one  years  old.  It  was  aeeompanied  by  slight 
dribblini;  and  was  reeoffnized  by  air  iullation  so  that  "the  air  was 
retlnxed  back  from  the  t)bstru('tion  ])resented  by  the  c'omi)ressor  and 
lit'teil  up  the  vahe,  bringing;  it  i)lainly  into  view  and  establishing  the 
diagnosis  beyond  doubt.  We  should  strongly  suggest  the  use  of  air- 
inHation  in  the  diagnosis  of  this  variety  of  vah'ular  formation,  believing 
that  it  aiVords  a  more  certain  method  of  diagnosis." 

The  author  has  had  one  remarkable  ease  of  valve  formation,  dorsally 
placed,  admitting  a  filiform  for  about  1  cm.  having  a  large  cavity  and 
three  or  four  crypts  easily  seen  near  its  outlet,  which  faced  caudad. 
The  fla])  ovorlying  the  valve  was  cut  through  with  the  high-FretpuMicy 
current  of  Oudin  which  made  the  halves  shrivel  and  i)ermitted  drain- 
age of  the  exudate  and  cure  of  the.  case. 

Diverticula. — In  the  urethra  di\'erticuhun  is  of  two  forms,  either 
congenital  and  due  to  malformation  or  acquired  and  rising  through  the 
obstruction  of  stricture.  In  the  ojiinion  of  the  author  the  former  is, 
strictly  speaking,  diverticulum  and  the  latter  sacculation  exactly  as  in 
the  bladder.  The  true  diverticulum  is  infantile  in  its  occurrence  and 
diagnosis  and  rests  on  clinical  signs  rather  than  on  urethral  exploration 
with  the  urethroscope  or  otherwise.  Sacculations  are  common  with  all 
severe  stricture  cases,  are  easily  detected  through  a  urethroscopy 
caudad  to  a  filiform  stricture  after  the  same  has  been  dilated  or  divided. 
In  some  cases  prior  to  relief  of  the  stricture  air  or  water  may  be  gently 
forced  through  it  and  ])roduce  a  bidging  between  the  cutoff  muscle  and 
the  proximal  aspect  of  the  node.  Occasionally  intelligent  ])atients  note 
it  during  urination  and  ask  the  cause.  Chronic  inflammation  is  more 
or  less  actively  present  everywhere  in  the  pouch,  whose  walls  come  and 
go  with  the  dilating  mediimi — urine,  water  or  air.  The  floor  of  the 
urethra  is  chiefly  compromised  because  unsu])]:)orted  b\'  the  corpora 
cavernosa  and  thus  the  floor  thins  out  to  touch  and  view  and  becomes 
the  common  site  of  the  sacculations.  The  lesion  is  essentially  ])er- 
manent  but  considerable  restoration  may  follow  proper  relief  and  after- 
treatment  of  the  stricture. 

Treatment. — The  anatomical  malformations — the  vahes,  diverticula 
and  sacculations — are  relieved  by  dixision  with  the  knife  or  the  Oudin 
current.  The  author's  practice  has  been  to  divide  the  band  with  the 
current  down  the  middle,  so  that  two  flaps  are  created  which  rapidly 
shrivel.  The  burned  margins  do  not  bleed  and  do  not  ten<l  to  unite  as 
they  would  and  often  do  after  cutting.  To  obtain  this  result  the 
burning  must  be  carried  from  the  free  margin  down  to  and  through  the 
base  where  it  unites  with  the  surface  of  the  canal.  Valves  may  be 
spread  open  and  made  tense  by  the-air  dilatation  and  then  divided  or 
sparked.    Sacculations  are  important  in  their  relation  to  stricture  in  the 

'  Cystoscopy  and  Urclliroscopy,  I'Jlo,  pp.  l'J8  u.ud  I'J'J. 


NONGONOCOCCAL  U'JSfONS  IN  URErifR/T/S  GGl 

proximal  mucosa  where  they  must  be  sought  and  relieved,  'i'he  after- 
treatment  reduces  the  secondary  reaction  and  cares  for  the  follicles 
often  present  nnder  cover  of  the  valve  or  within  the  cavity  of  the 
sacculation. 

Special  Inflammations  and  Infections. — Varieties. — I'nder  the  group 
of  special  invasions  of  the  uretlwa  arc  found  ciiieHy  catarrhal,  suppura- 
tive, herpetic,  tuberculous,  chancroidal,  syphihtic  and  cystic  infhmi- 
mation,  of  which  each  deserves  descri])tion  of  the  urethroscopic  findings. 
Each  has  been  fully  described  in  the  clinical  sections  of  this  work. 

Catarrhal  Urethritis. — ^As  already  noted,  the  exciting  cause  of  this 
lesion  is  the  Micrococcus  catarrhalis,  which  must  be  recovered  for  the 
diagnosis,  usually  acting  in  a  diathetic  subject.  The  urethroscopic 
picture  is  similar  to  that  seen  in  chronic  gonococcal  urethritis  but  very 
mild  in  degree  and  without  serious  complications  or  sequels.  Chief 
among  the  lesions  is  an  indolent  hyperemia  with  mucous  discharge 
of  rather  long  duration  and  resistant  to  treatment.  The  mucous  crypts 
discharge  mucus  and  mucopus  but  never  pus  and  the  urine  is  apt  to 
show  strings  and  clouds  rather  than  shreds  of  exudate.  The  great 
value  of  the  urethroscope  is  to  secure  specimens  for  culture  from  these 
crypts.  The  termination  of  the  inflammation  is  in  recovery  without  the 
numerous  sequels  and  permanent  lesions  of  gonococcal  disease. 

Treatment. — Urethroscopy  may  prove  too  violent  for  catarrhal 
manifestations  and  must  be  abandoned  if  unfavorable  reaction  ensues. 
In  many  cases,  however,  individual  glands  may  be  found  and  treated 
in  the  same  manner  but  with  more  gentle  means  than  those  described 
for  gonococcal  glands.  Catarrh  about  other  lesions  as  already  noted 
is  one  of  the  most  frequent  fields  of  treatment  for  this  form  of  inflam- 
mation. Internal  medication  for  the  catarrhal  tendency  with  tonics 
and  the  like  must  always  be  included.  Cure  is  sufficiently  described  in 
the  clinical  portion  of  the  text  (page  73). 

Suppurative  Urethritis. — As  shown  in  the  clinical  paragraphs  on  this 
subject  the  cause  of  nongonococcal  suppuration  within  the  urethra  is 
any  of  the  common  pyogenic  organisms.  The  commonest  are  the 
streptococcus,  staphylococcus  and  the  Bacillus  coli.  The  urethroscopic 
picture  ma}'  duplicate  all  the  clinical  features,  course  and  termination 
seen  in  gonococcal  urethritis.  The  complications  and  termination  are 
closely  analogous.  The  bacteriology  rendered  definite  through  the 
urethroscope  is  the  sole  diagnostic  distinction. 

Treatment. — Infection  with  the  pyogenic  organisms  so  closely  dupli- 
cating the  symptoms  and  sequels  of  that  with  the  gonococcus  likewise 
reiterates  the  indications  for  treatment  with  the  lu-ethroscope.  The 
reader  is  therefore  referred  to  Gonococcal  Urethritis  (page  52)  for  the 
details  of  treatment  and  cure. 

Herpetic  Urethritis. — Cold  sores  within  the  urethra  as  elsewhere  on 
the  body  are  caused  by  an  infection  and  are  usually  accompanied  by 
the  same  lesion  elsewhere,  such  as  on  the  glans  and  prepuce.  For  this 
reason  herpes  of  the  urethra  is.  not  a  primary  but  an  associated  lesion 
arising  with  the  same  aft'ection  in  other  parts.    It  is  not,  exactly  speak- 


662  rh'KTiiii'oscory 

ing,  secondary  only  in  the  sense  that  all  other  herpes  is  secondary.  The 
urethroscopic  picture  is  that  of  an  external  herpes  passing  through 
the  regular  stages  of  an  iuHanied  tender  jiapule.  later  surmounted  by  a 
vesicle  which  hursts,  leaving  a  small  ulcer.  It  has  little  significance 
except  the  danger  of  crt)ss  infection  and  the  gri'at  pain  during  its  acme, 
greatly  increased  by  urination.  The  peculiar  angry  base,  superficial 
ulcer  and  the  absence  of  the  bacillus  of  l)ucre>'  and  of  the  Tre])onema 
l)allidum  distinguish  it  from  chancroid  and  chancre.  Heri)es  termi- 
nates without  scar  or  other  lesion  unless  it  suH'ers  mixed  infections 
and  thereafter  becomes  a  totally  ditl'erent  pathologic  entity. 

Treatment. — The  urethroscope  is  applied  only  in  the  chronic  period 
of  the  lesion  after  the  anger  of  the  invasion  has  ceased  and  treatment 
through  the  instrument  nuist  meet  the  indications  of  sterilizing,  dry- 
ing and  healing.  Kndourethral  lesions  are  very  difficult  to  reach  and 
probably  the  mild  desiccating  spark  of  the  high-frequency  current  of 
Oudin,  as  shown  in  the  soap  test  on  p.  501,  is  the  best  application.  It 
should  be  given  very  briefly'  and  for  only  superficial  reaction.  One 
sitting  is  usually  sufficient.  Aftertreatment  is  that  of  a  very  mild  hand 
injection  such  as  argyrol,  3  per  cent,  to  10  per  cent.  Cure  is  well 
dismissed  with  the  details  given  in  the  clinical  text. 

Tuberculosis. — The  disease  is  regarded  as  primary  or  secondary  in 
the  urethra,  but  it  is  very  doubtful  whether  primary  tuberculosis  in 
the  strict  sense  ever  occurs  in  the  urethra  to  the  exclusion  of  foci 
elsewhere.  In  animal  experimentation  the  inoculation  of  the  disease 
in  male  rabbits  has  been  attended  with  success  in  the  hands  of  Baum- 
garten,^  quoted  by  Ahrens.-  Kraske^  claims  that  it  does  occur,  while 
Hogge^  states  positi\'ely  that  there  is  no  record  of  proved  primary 
tuberculous  urethral  lesions. 

In  secondary  tuberculosis  is  presented  a  familiar  experience.  Penile 
lesions  such  as  those  of  the  glans  and  prepuce  may  extend  into  the 
canal  by  continuity  and  others  reach  the  lu'cthra  by  perforation,  such 
as  the  cases  of  Kraske^  and  Hartmann.''  By  far  the  most  important 
secondary  cases  are  those  in  which  the  primary  lesions  are  in  the  kidney, 
bladder,  prostate,  seminal  vesicles,  vasa  deferentia  or  testicles,  from 
which  they  reach  the  urethra  in  the  urinary  or  seminal  stream  or 
through  the  blood  or  lymphatic  vessels. 

The  concurrence  varies  with  age,  sex  and  general  epidemiology. 
As  to  age  the  third  decade  of  life  during  the  great  activities  of  the 
sexual  system  is  the  most  common.  As  to  sex,  males  are  much  more 
often  afflicted  than  females,  according  to  Ahrens,''  who  notes  only  four 
reports  in  females.    This  fact  may  be  due  to  the  short  canal  and  the 

'  Quoted  by  Ahroiis,  but  not  in  the  library  of  the  New  York  Academy  of  Medicine. 
■  Beitrage  zur  klin.  Chir.,  1891-92,  viii,  312. 
3  Beitriige  z.  pathol.  Anat.,   1891.  x,  204. 
*  Ann.  des  Malad.  des  Org.  Gen.-urin.,  1901,  xix,  1486. 
'  Centralbl.  f.  Chir.,  1888,  xv,  889. 

'  Bull,  et  M6m.  Soc.  de  Chirurgie  de  Paris,  1906,  xxxii,  974,  and  Trav.  de  Chir.  Anatomo- 
Clinique,  p.  278. 

'  Beitr.  zur  klin.  Chir.,  viii,  312. 


NONGONOCOCCAL  LESIONS  IN  UliLTIIIilTIS  00:^. 

absence  of  neighboring  organs,  such  as  the  prostate,  vesicles  and 
testicles,  which  are  so  often  invaded.  Statistics  vary  from  a  fraction 
of  1  per  cent,  to  4  per  cent.,  which  makes  the  disease  relatively 
rare  even  among  tuberculous  patients.  Halle  and  Metz^  found  it  in 
12  out  of  KK)  patients  or  0.75  of  1  per  cent.  Ahrens^  collected  433  cases 
from  reports  of  Steinthal,  Krzywicki,  Pavel  and  others  and  found  onl\' 
18  urethral  lesicms,  or  about  4  per  cent. 

As  to  site,  the  posterior  urethra  is  most  commonly  invaded  probabl\- 
through  the  influence  of  the  sexual  glands — prostate  and  testicles  with 
the  seminal  vesicles  and  funiculi.  These  facts  still  further  tend  to 
prove  the  secondary  tendency  of  the  disease,  so  that  one  must  respect 
foci  in  these  organs  and  in  the  glands  of  Cowper. 

The  urethral  picture  is  much  the  same  as  that  of  tubercles  or  tuber- 
culous ulcers  in  the  bladder.  The  tubercles  may  give  few  or  no  symp- 
toms and  will  not  often  be  discovered  unless  systematic  investigation 
with  the  urethroscope  is  adopted.  Ulcers,  therefore,  predominate  in 
the  reports.  The  tubercles  appear  as  rounded  yellow  or  white  spots 
centered  in  hyperemic  zones  of  infiltration  and  edema,  as  constant 
elements.  The  tubeicle  itself  is  the  densest  point  of  the  infiltration 
and  ready  to  necrose  from  cellular  proliferation.  Their  size  is  usually 
small  but  may  be  large.  The  exact  image  and  magnification  of  the 
lateral  fenestrum  urethroscope  permit  easy  detection  of  them  as  a 
rule.  Greater  difficulty  is  found  in  the  terminal  fenestrum  instrument. 
The  ulceration  is  a  still  later  condensation  resulting  in  devasculariza- 
tion  and  centric  death.  The  floor  is  ragged  and  uneven,  the  edges 
punched  and  elevated,  closely  resembling  a  clean  chancre.  Later  by 
extension  and  mixed  infection  the  destructive  ulcer  is  seen  resembling 
a  phagedenic  chancre  with  marked  infiltration  and  undermining.  Kidd^ 
believes  that  extension  forward  is  accompanied  by  change  in  the  tuber- 
culous characteristics.  It  is  probable  that  the  urinary  and  sexual 
streams  provide  for  extension  caudad  more  rapidly  than  the  destructive 
action  of  the  lesion  carries  it  toward  the  bladder.  In  the  anterior 
urethra  the  bulb  is  the  most  common  site  exactly  as  it  invites  gono- 
coccal chronic  lesions. 

In  the  prostatic  urethra  the  lesions  are  always  associated  with  renal, 
ureteral,  vesical,  prostatic,  testicular,  vesicular  or  funicular  deposits. 
From  these  points  they  extend  downward  and  form  foci  usually  in  the 
prostatic  fossettes  or  upon  the  colliculus.  The  author  has  had  a  beau- 
tiful example  of  the  process  in  a  man  having  tuberculosis  in  the  right 
kidney,  in  the  bladder  about  the  right  ureter  and  in  the  right  testicle 
and  vesicle.  The  bacilli  were  numerous  in  the  urine.  Posterior  urethro- 
scopy revealed  tubercles  around  the  colliculus  and  in  both  prostatic 
sinuses.    Ulceration  had  not  yet  occurred. 

In  the  diagnosis,  the  discovery  of  antecendent  foci  is  all-important. 
The  simple  tubercle  is  surrounded  by  a  zone  of  redness  and  very  soon 
central  ulceration  appears.    The  subsequent  condition  is  t\'pical.    In 

1  Ann.  des  Mai.  des  Org.  Gen.-urin.,  1903,  xxi,  481.  "  Loc.  cit. 

'  Trans.  Path.  Soc,  vol.  Ixxxix,  p.  185. 


664  VRETiinnscnry 

the  early  stajres  it  ditfers  from  chancre  in  hv'uuj:  located  almost  always 
in  the  deep  urethra  and  rarely  around  the  meatus,  whereas  chancre  is 
never  in  the  deep  urethra  but  alw  ays  in  the  first  few  centimeters  of  the 
canal,  if  internal  at  all.  The  presence  of  ])rimary  tuberculous  lesions 
establishes  the  diH'erence.  Deeper  ulcerations  more  closely  reseiuble 
the  })rimary  sore  of  sy])hilis  excei)t  that  the  latter  extends  backward 
towartl  the  bladder,  whereas  the  former  eats  its  way  from  the  bladder 
toward  the  outlet.  Bacilli  of  tuberculosis  or  the  Treponemata  i)alli(la 
if  discovered  are  the  final  proof.  K])ithclioma  is  usually  nu>atal,  occurs 
in  the  later  decades  of  life  and  has  the  characteristic  clinical  findini-s 
of  lymphatic  involvement.  The  cancer  may  ulcerate  into  the  urethra 
from  adjoiniuf]:  organs,  especially  in  the  female. 

The  value  of  lu-ethroscopy  in  urethral  tuberculosis  is  that  it  not  only 
C(Mifirms  a  possible  (liaf:;nosis  but  also  indicates  operative  jjrognosis. 
Like  cystoscopy  in  a  suspected  case  it  should  never  be  omitted,  and 
also  like  cystoscopy  does  not  possess  material,  direct  dangers  for  the 
patient. 

Treatment. — The  presence  of  the  tubercle  bacillus  makes  urethro- 
scopy a  possible  source  of  danger  through  exciting  its  activities.  It 
is  essential,  however,  for  exact  diagnosis  and  thus  correlates  with 
the  cystoscope  in  this  aspect  of  treatment.  As  shown  in  the  previous 
paragraphs  on  this  subject  it  will  also  indicate  prognosis  and  the 
results  of  operation.  It  is  probable  that  relief  and  removal  of  the 
])rimary  focus,  as  in  the  upper  urinary  tract  or  the  sexual  glands  com- 
bined with  body  building  and  open-air  life  will  relie\'e  the  urethral 
foci  far  better  than  urethroscopic  applications.  It  is  these  elements 
of  aftertreatment  that  are  essential. 

Chancroidal  Urethritis. — As  fully  specified  under  chancroidal  lesions 
as  part  of  nongonococcal  urethritis  in  Chapter  II,  the  clinical  features 
will  need  no  repetition  here.  Like  tuberculosis  its  occurrence  is  by 
continuity  of  surface  or  by  perforation,  during  the  age  of  greatest 
sexual  activity  and  in  males  more  than  in  females.  The  common 
site  is  the  anterior  urethra  from  meatal  extension.  It  is  very  rarely 
literally  endourethral  and  primary.  It  may  occupy  any  point  of  the 
periphery  or  the  entire  periphery  of  the  canal  and  may  extend  a 
considerable  distance  toward  the  bladder. 

The  diagnosis  should  be  made  without  the  lu'cthroscopc  because  the 
lesion  is  acute  in  its  nature  and  the  instrument  causes  pain  and  trauma 
and  may  transfer  the  disease  to  deeper  parts.  The  chancroid  is  auto- 
inocula})le.  The  urethrosco])ic  ])icture  is  like  that  of  the  naked  eye, 
slightly  modified  by  the  special  illumination  and  restricted  field.  The 
floor  is  mouse-eaten,  sloughy,  grayish  to  red,  and  occasionally  hemor- 
rhagic, and  the  edges  are  always  undermined  and  mo\'able  with  an 
instrument  such  as  a  filiform  or  probe.  A  zone  of  acute  redness  and 
infiltration  is  about  the  sore  and  the  lymphatics  are  painful  and 
involved  early.  The  exudate  contains  blood,  })us  and  detritus  and 
the  bacillus  of  Ducrey,  whose  presence  distinguishes  the  lesicm  from 
chancre  and  tuberculosis. 


NONGONOCOCCAL  LESIONS  IN  UliETII lilTlS  OG.j 

Treatm.ent. — Infectimi  of  the  urethra  with  the  hacilhis  (^f  Ducrcy  is 
fortunately  chiefly  at  the  meatus  when;  it  may  he  reaehed  without  the 
urethroscope.  If  withiu  the  canal  care  must  he  tak'en  not  to  pass 
beyond  the  lesion  and  infect  a  new  focus.  Sterilization  and  removal 
of  the  slough  after  cauterization  followed  by  stimulation  of  the  granu- 
lations to  healthy  healing  are  the  indications  and  the  means  have  beeYi 
described  in  the  treatment  of  chancroid  as  a  form  of  nongonococcal 
urethritis  in  the  clinical  chapters  of  this  work.  (Jreat  care  must  be 
exercised  not  to  damage  the  annexa  and  thus  extend  the  disease  to  new 
foci  during  attempts  at  relieving  the  primary  sore.  The  aftertreatment 
is  involved  with  the  urethritis  of  local  character  often  associated  with 
the  chancroid.  Gentle  measures  as  recommended  for  catarrhal  urethritis 
are  required.    Cure  is  fittingly  discussed  in  the  clinical  pages. 

Syphilitic  Urethritis.— The  full  picture  of  syphilis  of  the  urethra  is 
drawn  in  the  clinical  paragraphs  on  page  37  so  that  no  rehearsal  here 
is  needed.  The  forms  are  primary  as  the  chancre  and  secondary  as  the 
mucous  patch. 

In  the  primary  stage  the  chancres  are  typical  or  mixed.  Either 
lesion  may  be  more  common  in  occurrence  than  is  supposed  because  it 
causes  few  symptoms.  The  initial  lesion  through  its  enlargement,  pain 
and  obstruction  is  the  more  often  noted  by  the  patient  and  has  as  its 
site  the  meatus  most  commonly  and  just  like  the  chancroids,  it  is 
rarely  cephalad  to  the  fossa  navicular  is.  Keyes^  has  reported  a  chancre 
about  U  inches  within  the  canal.  The  size  is  large  or  small,  occupying  a 
limited  or  great  portion  of  the  circumference  and  extent  of  the  channel 
during  the  sexual  age  and  chiefly  in  the  male.  Relatively  this  manifes- 
tation is  very  rare. 

The  diagnosis,  like  that  of  chancroid,  is  best  made  without  the  ure- 
throscope because  of  the  pain  and  injury  of  the  part.  The  forms  of 
chancre  described  by  Taylor^  should  be  borne  in  mind,  otherwise 
confusion  may  arise.  The  urethroscopic  picture  is  an  ulcer  with  a 
smooth,  glossy  floor,  clean-cut  indurated  edges  with  slight  eversion  but 
no  undermining,  rather  regular  outline  and  serous  exudate.  Pus  and 
blood  may  be  present.  The  Treponema  pallidum  is  in  the  discharge 
and  the  substance  of  the  sore.  The  lymphatics  are  late  and  the  skin 
and  its  appendages  still  later  in  their  involvement.  The  mixed  chancre 
nearly  duplicates  the  chancroid,  especially  when  the  pyogenic  infection 
temporarily  overshadows  the  syphilitic  element. 

The  differential  diagnosis  rests  on  the  presence  of  spirochetes,  the 
Wassermann  blood  test,  and  later  on  the  secondaries  of  the  skin. 
Tuberculosis  differs  from  syphilis  m  usually  having  antecedent  lesions 
elsewhere  in  the  body  or  the  urogenital  tract  and  niunerous  other  tuber- 
cles or  ulcerations.  The  bacilli  may  be  in  the  urine  or  recovered  from 
the  sore,  the  tuberculin  test  may  be  positive  and  systemic  emaciation 
and  secondary  anemia  may  be  present.  Cancer  differs  m  having  a 
much  later  age,  in  being  rarely  primary  but  usually  secondary  by 

'  Ann.  Jour.  Dermatol,  and  Syph.,  1870,  i,  37. 

2  Genito-urinary  and  Veneieal  Disease,  Third  Edition,  p.  500. 


C^Cy(\  VRETFlROSCOpy 

contiguity  from  the  glaiulular  striictiires  about  the  deep  urethra.  The 
prostate  and  bhidtler  in  men  and  the  vagina  and  uterus  in  women  are 
common  sources.  Infiltration  beyond  the  lesions,  fixation  of  the  entire 
region  and  ilefinite  spread  through  the  lyni])hatics  may  all  be  i)resent 
very  early.  There  is  neither  Trei)onema  i)allidum,  Wassermann  blood 
test  nor  secondary  lesions  in  cancer. 

In  secondary  s^-philitic  urethritis  the  form  seen  is  the  mucous  patch. 
The  flora  of  the  urethra  may  provide  for  the  frequent  presence  of  these 
lesions.  The  writer  doubts  this  sui)])()sition  because  of  the  rarity  of 
symptoms  and  of  the  fact  that  if  present  the  patches  would  persist  for  a 
long  time  in  so  closed  a  canal.  The  female  urethra  is  much  more 
accessible  and  does  not  show  ])atches  in  any  material  frecpiency.  In 
any  other  mucosa  the  lesion  is  very  mild  in  its  manifestations  and  in 
the  author's  observation  it  has  been  seen  only  at  the  meatus  in  the 
male  and  around  the  vestibule  and  meatus  in  the  female.  Some 
observers  claim  to  have  seen  severe  symptoms  occur  in  their  presence, 
notably  Bassereau'  and    Bumstead.- 

The  urethroscopic  picture  is  that  of  a  silvery  spot  or  spots,  sodden, 
soft,  prominent,  rarely  hemorrhagic  or  tender,  identified  with  the  sur- 
face so  that  it  does  not  rub  ofi".  It  is  due  to  proliferation  of  the  epithe- 
lium. The  Treponema  pallidum  and  the  Wassermann  blood  test 
should  be  looked  for.  The  lesions  terminate  under  systemic  treatment 
aided  by  local  cleanliness,  whose  absence  was  manifest  in  the  cases 
of  the  author  and  filth  was  obviously  one  of  the  causes. 

Treatment. — The  chancre,  like  the  chancroid,  is  usually  meatal  in  its 
occurrence  and  rarely  endourethral,  but  the  mucous  patch  may  occur 
within  the  urethra  and  require  urethroscopic  applications.  Cleanliness 
of  the  surface  and  urethra  through  urinary  antiseptics  and  frequent 
urination  are  the  first  indications.  Violent  irritation  with  caustics 
and  overstimulation  will  make  the  chancre  worse  and  often  advance 
the  patch.  Systemic  measures  must  never  be  omitted  and  always  con- 
tinue after  the  lesions  ha\e  healed.  Thus  they  are  an  important  part 
of  the  aftertreatment  combined  with  urinary  antiseptics  and  diluents 
provided  the  urine  is  foul.  Purification  of  such  urine  avoids  the 
irritation  so  often  seen  as  the  basis  of  mucous  lesions. 

Bassereau's  article  has  no  case  reports,  but  only  an  inference  that  a 
urethral  discharge  during  an  outbreak  of  secondary  syphilis  might  be 
due  to  mucous  ])atches  in  the  urethra.  There  is  only  one  case  of  mucous 
patch  in  Bassereau's  collection  and  that  was  at  the  meatus. 

Biunstead  also  has  no  case  reports  but  makes  an  indefinite  statement 
which  infleed  ma\'  have  been  borrowed  from  Bassereau.  Of  course, 
both  these  authors  are  far  in  advance  of  bacteriologic  days.  Cure 
is  well  detailed  in  the  clinical  section  on  page  804. 

Prostatic  Utricular  Cyst. — Inasmuch  as  this  lesion  is  caused  by  inflam- 
mation it  should  be  considered  under  special  inflammations  in  urethro- 
scopy.   The  cause  is  occlusion  of  the  opening  of  the  utriculus,  retention 

1  Trait6"des  Affections  de  la  Peau  Symptomatique  de  la  Syphilis,  Paris,  1852,  p.  356. 
-  The  Pathology  and  Treatment  of  Venereal  Diseases,  1865,  p.  545. 


NONGONOCOCCAL  LKHIONH  IN  IJkKTflJilTfS  007 

of  its  normal  exudate  and  oyh:tic  development.  It  is  a  medical  furiosit\', 
truly  congenital  and  hence  infantile  in  its  presence.  It  is  very  doubtful 
whether  it  is  ever  seen  in  the  adult.  'I'he  author  has  never  discovered 
one.  In  Europe,  Englisch^  made  a  study  of  it  among  70  autopsies  of 
newborn  infants  and  found  five  specimens.  In  this  country  Cabot^ 
reports  that  it  probably  does  not  occur  among  adults  and  ncjtes  f)ne 
autopsy  case.  Among  adults  the  best  report  of  a  possible  case  is  that 
of  Klotz,''  who  is  by  no  means  positive  of  the  diagnosis  but  whose 
description  is  strongly  suggestive  of  the  lesion  Klotz  quotes  Belfield 
in  this  paper. 

The  urethroscopic  picture  is  like  that  of  any  other  mucous  membrane 
cyst  but  located  in  the  colliculus.  The  color  is  bluish-white  with  marked 
translucency,  elasticity  and  tension.  An  acquired  case  would  show 
the  signs  of  chronic  urethritis  in  the  deep  urethra  and  atrophy  of  the 
colliculus  might  be  expected. 

Other  instructive  contributions  are  those  of  Springer^  and  Belfield.'^ 

Cysts  of  the  Follicles. — Occlusion  of  the  mucous  crypts  is  not  uncom- 
mon and  has  the  foregoing  characteristics  in  themselves  and  in  their 
annexa. 

Treatment. — The  recognition  of  these  lesions  is  the  most  important 
and  the  urethroscope  is  the  one  means  of  certainty.  The  cysts  may  be 
punctured  with  the  knife  or  stripped  with  the  high-frequency  current 
of  Oudin  or  the  d'Arsonval  current,  as  already  described.  Thus  cysts 
are  dealt  with  in  much  the  same  way  as  infected  glands  with  infiltrated 
ducts.  Around  the  colliculus  great  precautions  must  be  observed  in 
order  to  avoid  atrophy  of  that  body  and  closure  of  the  ejaculatory 
ducts.  Again  the  aftertreatment  must  respect  the  associated  catarrhal 
or  suppurative  conditions.  Cure  is  clearly  outlined  in  the  clinical 
paragraphs  on  page  109. 

Filiform  Strictures. — Buerger*^  employs  direct  vision  through  his 
operation  urethroscope  shown  in  Figs.  175-177.  The  instrument  has  a 
terminal  fenestrimi,  irrigation,  direct  vision  telescope  and  ample  instru- 
ment tube.  The  sizes  range  in  even  numbers  from  22  to  28  French. 
The  average  is  24  French.  The  left-hand  figure  shows  the  large  instru- 
ment tube  in  the  sheath,  which  has  a  urethral  and  vesical  obturator. 

The  technic  requires  the  lithotomy  or  analogous  postine.  The 
urethroscope  touches  the  stricture,  the  obturator  is  replaced  by  the 
telescope,  the  urethra  is  held  or  bandaged  water-tight  around  the  sheath, 
light  turned  on,  irrigation  started  and  the  opening  penetrated  with  a 
Phillip's  or  whalebone  bougie  directly  under  the  eye.  Thereafter 
dilatation  is  continued  or  internal  urethrotomy  performed  as  indicated. 
The  advantages  of  this  method  are  obvious. 

Neoplastic  Urethritis. — As  elsewhere,  the  classes  are  malignant  and 
benign.    The  site  of  the  malignant  tumors  is  rarely  endourethral  but 

1  Med.  Jahrbiicher,  1873,  p.  61.  ■  Tr.  Am.  Assn.  Gen.-urin.,  Surg.,  1906,  i,  101. 

3  New  York  Med.  Jour.,  January  26,  1895. 

*  Zeitschr.  f.  Heilkunde,  1898,  xix,  459-474. 

6  Jour.  Am.   Med.  Assn.,   1894,  xxii,  574. 

«  Surg.,  Gynec.  and  Obst.,  March,  1918,  xxvi,  No.  3,  pp.  347-350. 


GGS 


URETHROSCOPY 


u>^uallv  contiiiuous,  arisiiii,'  from  tin-  prostate  and  ]>la(l(ltT  In  males  but 
in  females  the  uterus  replaces  the  prostate.     The  beni.^u  neoplasms 


Fig.  175.  Fig.  176.  Fig.  177. 

Fig.    175.— New  urethroscopic  tul.o  witli  niff,  irrigating  faucets,  and  catheter   outlet. 

(Buerger.) 

Fig.  176. — Obturator  for  anterior  urethra.     (Buerger.; 
Fig.  177. — Telescope.     (Buerger.) 

are  much  more  frequently  urethral,  e.specially  papilloma,  polypi  and 
gramiloma.     True  papilloma  of  the  urethra  is  seen   although  many 


NONGONOCOCCAL  LESIONS  IN  UHETIIIilTIS  669 

forms  of  exuberant  fframilations  of  the  (leej)  iinithra  are  wrongly  so 
termed.  The  author  has  had  a  case  in  which  a  j;apilloma  was  present 
in  the  bladder  near  the  left  ureter  in  the  ureterotrigonal  zone,  anrl 
another  in  the  urethra  near  the  sphincter  vesical  muscle. 

The  frequency  is  that  of  tumors  everywhere  in  the  body  in  the 
mucous  membranes:  papilloma,  polypi,  cysts  and  malignant  develop- 
ments. 


Fig.  178. — Universal  m'ethroscope  with  filiform  in  place.     (Buerger.) 

Papilloma — Mucous  papillary  outgrowths  are  by  no  means 
uncommon  in  other  membranes  of  the  body  and  arise  from  various 
causes.  In  the  urethra  they  have  an  anatomical  and  pathologic  basis. 
The  anatomical  origin  is  as  follows:  There  are  scattered  papillae  in  the 
bulbous  urethra  between  the  triangular  ligament  and  the  penoscrotal 
juncture.  Henle^  states  that  papillae  are  very  numerous  in  the  strati- 
fied epithelial  zone  of  the  canal  for  about  4  cm.  backward  from  the 
meatus.  The  single  growths  arise  from  the  solitary  papillae  and  the 
•nested  growths  from  the  multiple  papillae.  The  pathologic  basis  is 
idiopathic  and  inflammatory.  In  the  idiopathic  cases  the  author 
thinks  he  has  seen  a  tendency  to  warts  elsewhere  in  the  body,  such  as 
the  skin,  although  the  history  of  inflammation  and  infection  may  be 
absent.  Oberlaender-  has  described  "urethritis  papillomatosa"  invad- 
ing zones  of  dense  infiltration  during  chronic  urethritis.  There  is  no 
question  in  the  author's  observation  that  such  areas  almost  always 
have  much  granulation  tissue  proximal  to  them.  It  therefore  follows 
that  papillary  developments  are  due  either  to  gonococcal  or  syphilitic 
chronic  urethritis  especially  about  strictures  and  infiltrations.  The 
granulomata  seen  in  these  regions  so  commonly  may  be  only  other 
forms  of  papilloma. 

The  common  site  of  single  papillomata  is  in  the  proximal  anterior 
urethra  where  the  solitary  papillae  abound  as  pointed  out  by  ]Mark^ 
The  multiple  urethral  warts  are  associated  with  those  of  balanoposthitis 
about  the  prepuce,  glands  and  meatus  in  men  and  with  those  of  vulvitis 
in  women.  The  distribution  is  usually  in  the  terminal  anterior  urethra 
allied  to  external  papillomata,  as  already  shown,  but  they  may  extend 

1  Handbuch  der  Sj'st.  Anat.,  ii,  p.  433. 

2  Viertelj.  f.  Dem.  u.  Syph.,  1SS7,  xiv,  1077. 
5  Loc.  cit. 


670  URETHROSCOPY 

along  the  canal  more  or  less  as  a  whole,  as  originally  shown  l>y  \'aj(la,' 
who  was  the  first  to  describe  them  in  the  deep  portions  of  tiie  canal. 
Universal  involvements  ha\c  lu'cn  described  by  Obcrlaender,'  by 
Desquier^  who  enii)loyed  the  endoscope  and  aut()i)sy  findings,  and 
Rebonl-"  notes  a  case  in  a  \\()inan  with  diagnosis  by  inspection  and 
vaginal  tonch.  \  adja  in  lii>  report  collected  cases  from  a  number  of 
other  obscrxcrs  and  sinrc  tiu'  work  of  these  various  authorities  their 
descrijitions  fiave  been  fully  corroborated.  The  author  lias  frequently 
seen  pa])illoniata  in  the  deep  urethra,  the  bulbous  urethra  and  the 
terminal  portion  of  the  i)enilc  urethra  and,  of  course,  in  the  bladder, 
but  he  never  has  seen  the  lesions  scattered  along  the  entire  canal, 
including  the  bhuldcr. 

The  urcthrosco])ic  ])icture  is  best  obtained  through  a  terminal  t'cn(>s- 
trum  instrument  because  the  inflation  with  the  air  ])rojects  the  urethra 
beyond  the  instrument  for  a  considerable  distance  before  the  edge  of 
the  tube  damages  the  lesion.  Thus  the  number,  attachment  and 
groui)ing  of  the  i)ai)iIlomata  may  be  seen  with  least  difficulty  by  advanc- 
ing the  instrument  from  the  meatus  toward  the  bladder  and  inserting 
the  obturator  as  required.  The  lateral  fenestrum  instrument  has  a 
tendency  to  tear  the  lesions  away.  The  growths  appear  like  ordinary 
venereal  warts,  are  single  or  multiple,  sessile  or  pedunculated,  thick 
or  thin,  similar  to  a  cock's-comb  with  shallow  or  deej)  se])arati()ns. 
TJiey  are  of  a  pale  pink  or  whitish  color,  slightly  hemorrhagic,  super- 
ficially attached,  tearing  ofY  and  breaking  easily  and  leaving  a  shallow, 
bleeding  base.  They  are  often  surrounded  with  mucus  or  mucopus 
which  their  mechanical  presence  provokes  and  they  are  themselves 
moist  and  sodden.  They  do  not  terminate  spontaneously  but  must  be 
removed. 

Polypus. — The  pathology  of  these  lesions  must  be  accurately  followed, 
as  pointed  out  by  Lewis  and  ]Mark^  among  recent  American  writers, 
who  divide  them  properly  into  the  fibrous  and  vascular  forms.  Among 
the  fibrous  type  are  fibromata,  consisting  of  ])ure  fibrous  tissue,  fil)ro- 
myxomata,  composed  of  mucous  and  fibrous  tissue,  and  fibromyomata, 
comprising  a  mixture  of  fibrous  and  muscular  elements.  The  vascular 
form  contains  caruncles  seen  chiefly  in  women.  It  is  essential  to 
exclude  from  the  polypi  both  papillomata,  as  already  described,  and 
granulomata  or  exuberant  granulations  which  are  more  or  less  allied 
to  them. 

Fihroit.s  Poh/jji. — The  fibrous  elements  of  the  growth  are  pure  or 
mixed  with  mucous  and  muscular  elements  to  form  resi)ectively  the 
fibromata,  fibromyxomata  and  fibromyomata.  In  occurrence  they  are 
all  rare  especially  the  pure  fibrous  polyps  but  the  mixed  types  are  con- 
siderably more  common  especially  if  exuberant  granulations  may  be 
included  in  the  growths.  The  most  common  endourethral  form  is  the 
fibromyxoma  because  it  contains  so  largely  mucous  membrane  elements, 

'  Wien.  med.  Wchnschr.,  1882,  xxxii,  1098,  '  Loc.  cit. 

3  Soc.  Beige  de  Chir.,  December  28,  1890,  *  Assn.  franc.  d'uroL,  1896,  1,  39. 

^  Loc.  cit. 


NONGONOCOCCAL  LESIONS  IN  UHETIIlilTIS  071 

whereas  the  exourethral  type  is  the  fibromyoma  })eeause  its  muscle 
substance  is  developed  below  the  mucosa  and  crowds  it  into  the  lumen. 
The  site  is  in  the  bulbous  and  posterior  urethra,  exactly  where  the 
papillae  abound  and  where  folds  of  the  mucosa  and  muscularis  are  deep. 
Mark  says  in  the  work  already  cited:  "We  have  observed  postmortem 
a  case  of  multiple  fibromata  in  the  prostatic  portion  of  the  canal.  In 
this  case  there  were  six  distinct  polypi  scattered  over  the  inferior  wall 
and  side  of  the  prostatic  urethra." 

The  urethroscopic  picture  is  best  obtained  with  the  air  inflation 
instrument  for  the  same  reasons  as  given  for  papillomata.  The  growths 
show  a  reddish  or  pale  color  according  to  the  sclerosis  and  the  condition 
of  the  mucosa  as  it  lies  over  the  rounded  rather  smooth  form.  The 
attachment  is  pedunculated  in  the  fibromata  and  fibromyxomata  but 
sessile  for  the  fibromyoma.  The  annexa  almost  always  show  the 
presence  or  sequels  of  chronic  inflammation  and  the  lesions  have  no 
termination  unless  removed. 

Vascular  Polypi. — The  female  is  almost  solely  the  victim  of  this 
lesion,  which  is  described  under  urethroscopy  in  the  female  on  page 
679.  The  few  reports  of  this  lesion  in  males  are  confined  to  the 
fossa  navicularis  and  meatus.  Inasmuch  as  one  theory  of  these  lesions 
is  that  they  consist  of  erectile  tissue  occurring  in  woman  through 
maldevelopment  where  she  should  have  none,  it  is  difficult  to  under- 
stand how  the  true  caruncle  can  appear  in  men  exactly  where  erectile 
tissue  is  abundant  and  normal. 

Varicosities. — Groups  of  vessels  varicosed  and  similar  to  nevi  are 
common  in  the  female  urethra,  where  they  are  described,  but  very 
unusual  in  the  male.  Only  two  well-established  cases  have  appeared 
in  English  literature.  These  are  the  reports  of  Klotz^  and  Young, 
noted  by  Fowler.^    Full  quotation  is  warranted  in  each  instance. 

Case  of  Klotz:  "The  protruding  portion  of  the  mucous  membrane 
was  found  to  be  of  a  smooth  surface  and  a  dark  bluish  color,  of  the 
shape  and  size  of  a  coffee  bean,  sharply  defined  at  the  base  from  the 
dark  pink  surrounding  portions.  The  tumor  was  soft  and  easily  yielded 
to  the  pressure  of  the  tube,  although  on  introduction  it  seemed  to  offer 
a  slight  resistance.  On  close  inspection  within  the  tumor  a  number 
of  separate  cords,  separated  by  yellowish-white  lines  resembling  the 
rings  of  a  coil,  could  be  distinguished,  apparently  representing  dilated 
bloodvessels,  and  imparting  to  the  whole  mass  the  character  of  a 
cavernous  angioma." 

Case  of  Young:  "  Urethroscopic  examination  by  Dr.  Young.  Xo.  26 
Otis  tube  was  passed  into  the  prostatic  urethra,  but  it  was  impossible 
to  introduce  it  as  far  as  the  verumontanum.  The  anterior  portion  of  the 
prostatic  urethra  which  was  examined  showed  nothing  particularly 
abnormal.  The  membranous  urethra  was  also  about  normal.  As  soon 
as  the  bulbous  urethra  was  reached,  in  drawing  the  urethroscope  out- 
ward, the  picture  was  at  once  remarkably  abnormal.    Several  large, 

1  Loc.  cit.  ?  Johns  Hopkins  Hospital  Report,  xiii,  91, 


672  URETHROSCOPY 

deep  red,  irregular  masses  projected  into  tlie  lumen,  and  between  them 
were  depressions  of  a  dull  fjray  color  which  sufjfiested  ulceration  or  old 
scars,  but  were  jirobably  not.  This  condition  was  present  in  the  entire 
anterior  urethra.  As  the  instrunu'nt  was  drawn  slowly  out,  a  succession 
of  irregular,  rounded,  deci)  red  masses  ])rojcctcd  o\-cr  the  end  of  the 
endoscope;  these  were  apparently  eoxcrcd  by  healthy  nuicous  mem- 
brane, and  between  them  were  irregular  (lci)ressions  of  grayish  color, 
sui)i)osed  at  first  to  be  ulcers,  but  no  exudation  could  be  obtained  from 
them,  and  probing  did  not  cause  any  hemorrhage,  so  that  it  was 
e\ident  that  they  were  not  ulcers.  The  roundeil  dcej)  masses  which 
were  scattered  over  the  mucous  membrane  were  evidently  dilated 
bloodvessels.  There  were  no  ulcerations  to  be  seen  and  no  rui)tured 
vessels  or  definite  ])()ints  of  active  hemorrhage,  though  l)lood  con- 
stantly a})peare(l  in  the  endoscopic  field. 

Treatiiicuf — The  imi)ortant  manifestations  arc  papilloma,  l)olyp, 
caruncle  and  \arix.  The  urethroscope  records  exact  diagnosis  and 
offers  remo\al  or  destruction  with  the  snare,  electrocautery,  high- 
frequency  current  of  Oudin  in  the  desiccating  or  coagulating  strength 
as  shown  in  the  soap  test  noted  on  p.  501,  or  the  d' Arson val  current 
as  described  on  p.  501.  The  electrotherapeutics  are  the  best  and  treat- 
ments are  repeated  only  after  the  reaction  of  each  has  disiq)peared  or 
nearly  (lisa})peared.  The  aftertreatment  comes  in  when  the  growth  is 
entirely  gone  and  the  mucosa  is  closing  over  its  attachment.  ]\rild 
stimulation  of  this  point  may  be  required  and  is  best  given  through  the 
urethroscope  alternating  with  instillations  and  injections  according  to 
circumstances.  Inspection  of  the  urethra  at  long  and  regular  intervals 
to  determine  any  tendency  to  rcla])se  of  the  growth  is  a  very  im])ortant 
detail  of  the  aftercare.  Cure  will  in  the  pathologic  sense  mean  removal 
of  the  growth  so  that  no  return  occurs,  but  the  portion  of  the  mucosa 
in\'olved  is,  of  course,  destroyed,  usually  without  any  incon^'enience 
to  the  patient.  Symptomatic  cure  adds  the  absence  of  such  post- 
operative sequels  and  also  the  relief  of  secondary  catarrh  or  other 
discharge. 

Malignant  Neoplasms. — Under  this  classification  are  included  only 
carcinoma  and  sarcoma  of  the  urethra. 

Carcinoma. — The  forms  are  primary  and  secondary  as  in  all  other 
new  growths.  wSecondary  cancer  of  the  urethra  ulcerating  into  the 
canal  from  its  glandular  and  visceral  annexa  is  by  no  means  uncommon 
in  both  .sexes,  as  already  stated.  In  the  male  the  usual  origin  is  the 
prostate  and  in  the  female  the  vagina  and  utei*us,  and  in  both  sexes 
the  bladder.  The  primary  cancer  of  the  urethra  is  very  uncommon 
when  compared  with  carcinoma  in  general  and  with  other  urethral 
di.sease.  Its  actual  frequency,  according  to  well-established  cases,  is 
27  cases  in  the  male  and  36  in  the  female  on  the  authority  of  such 
recent  researches  as  those  of  Hall'  and  Lecene  and  Prat.'-  This  list 
includes  those  of  ab.solutely  fixed  diagnosis  and  others  could  be  added 

*  Ann.  Surg.,   March,   1904,  xx.xix,  .375. 

*  Hartmann'.s  Travaux  dc  Chirurgio  Anatome-Clinique,  1904,  p.  278. 


NONGONOCOCCAL  LESIONS  IN  (JUJ'JTH U/'I'/S  Ol'A 

in  which  it  is  douhtful.  The  majority  were  sf|u;uMoiis-cell('(l  cancer, 
especially  when  associated  with  chronic  infiainmiition  in  the  annexa 
of  stricture.  The  site  is  chiefly  in  the  bulbous  lu-etlira,  where  folds  and 
chronic  inflammation  are  common  and  where  the  most  severe  types 
of  anterior  stricture  are  encountered.  Such  hard  infiltrations  are,  as 
already  shown,  associated  with  benij^n  neoplasms,  and  from  this  fact  it 
follows  that  they  have  a  direct  bearing  on  cancer  formation  as  shown  by 
Hartmann.  As  in  other .  cancers  of  passages  in  the  body,  they  cause 
infiltration,  fixation,  obstruction,  hemorrhage,  destruction  and  lym- 
phatic involvement.  These  factors  complete  the  picture  but  suggestive 
outline  or  sketch  of  the  disease  is  furnished  by  bleeding  without  urina- 
tion or  erection. 

The  urethroscopic  picture  is  supplied  strictly  by  only  three  reports 
in  which  the  diagnosis  was  reached  by  the  urethroscope.  These  are 
the  cases  of  Gruenfeld,^  Oberlaender,^  and  Beck.'' 

These  cases  may  be  summarized  in  the  following  terms  as  showing 
variations  in  the  findings: 

Case  of  Gruenfeld. — ^The  lesion  was  carcinoma.  Insertion  of  a  straight 
tube  for  12  cm.  discovered  a  yellowish-white,  pedunculated,  polj'poid 
outgrowth.  A  second  flattened  tumor  was  situated  4  cm.  cephalad. 
This,  too,  was  yellow-white.  In  the  deep  urethra  the  entire  mucosa 
was  peculiar.  Near  the  colliculus  was  a  congested  band  curving  toward 
the  right  and  the  other  elements  of  the  picture  were  a  mass  placed 
across  the  canal,  partly  red  and  partly  pale,  with  a  surface  uneven, 
furrowed,  excavated  in  spots  and  vascular.  A  delicate  septiun  appeared 
during  withdrawal  of  the  urethroscope,  showing  a  hemorrhagic  livid 
zone  above  and  an  ulcerated  zone  below.  Changes  in  position  and 
relation  of  the  mass  disclosed  ulcers  and  in  the  lower  aspect  two  spots 
like  facets. 

Case  of  Oberlaender .—The  growth  was  a  squamous-celled  cancer. 
On  passing  a  27  F.  urethroscope  to  the  bulb  a  crescentic  whitish  sclerosis 
in  a  grayish  dry  annexum  of  mucous  membrane  was  encountered  and 
others  much  similar  were  scattered  along  the  canal  as  far  as  the  fossa 
navicularis  with  many  folds  and  follicular  and  glandular  involvement. 
This  growth  had  cephalad  to  it  a  red  and  raw,  irregular  and  friable, 
lobulated  and  raspberrylike  mass  which  came  into  the  field  clearly  on 
making  traction  on  the  penis. 

Case  of  Beck. — The  neoplasm  was  a  squamous-celled  carcinoma. 
The  mass  was  near  a  stricture,  hemorrhagic,  papillary  and  placed  on 
the  dorsal  and  right  walls  of  the  canal. 

Berkeley  Hill,  in  consultation,  urethroscoped  the  patient.  The 
tedious  report  lacks  definite  proof  of  stricture,  as  perhaps  intended. 
The  man  was  sixty-one  years  old,  and  at  eighteen  years  had  a  brief 
gonorrhea.     Stream  always  progressingly  reduced,  until  six  months 

1  Grilnfeld:  Die  Endoscopie  -der  Hariirohre  und  Blase,  Deutsche  Chirurgie,  Lief.  50, 
p.  193. 

-  Internat.  Centralbl.  f.  d.  Physiol,  u.  Pathol,  d.  Harn.  and  Sexualorgane,  1893,  iv,  244. 
3  Internat.  Clinics,  1892,  2,  S.  ii,  256. 
43 


(■)74  URETHROSCOPY 

before  consultation  oiil>-  Xo.  1  catheter  could  pass.  At  the  same  time 
there  was  a  swelling  in  the  perineum  and  dysuria.  Later  Xo.  6  catheter 
could  be  passed.  Catheter  life  at  home  soon  produced  hematuria. 
Admitted  to  hospital  with  hard  perineal  swelling,  o  x  12  inches.  X^o 
pain.  No  cachexia.  Prostate  and  menibrancnis  urethra  healthy.  No 
enlarged  lymph  nodes.  Xo  false  passage.  Stricture  four  inches  back 
from  meatus.  Perineal  section.  Palliative  procedure.  Death.  Xo 
autopsy.     Squamous-celled  cancer  judged  from    biopsy. 

The  diagnosis  will  be  furnished  early  with  the  aid  of  the  urethroscope, 
which  oilers  a  far  more  o])portune  moment  for  o])eration  and  thus 
avoids  relapses  and  recurrence.  In  many  of  the  records  the  disease 
was  known  only  liy  perforation  of  the  urethra  or  by  obstruction, 
extravasation  and  sinus  formation.  Hall  collected  21  cases  with 
absolutely  i)athologic  diagnosis,  in  which  the  report  of  Oberlaender 
was  the  only  one  in  which  the  tmiior  did  not  return  in  less  than  a  year 
after  hitervention.  Urethroscopy  and  diagnosis  are  required  in  the 
face  of  bleeding  independent  of  urination  or  erection,  altered  stream  or 
function  and  a  hemorrhagic,  warty  growth  during  the  carcinomatous 
period  of  life.  The  growth  may  be  snared  or  clipped  for  a  specimen, 
which  will  make  the  diagnosis  final.  These  growths  hiivv  no  termi- 
nation other  than  that  of  enlargement,  extension,  ulceration  and  metas- 
tases, which  are  delayed  but  a]>parently  ne\'er  a\oided  even  by 
operation. 

Sarcoma. — The  forms  are  primary  and  secondary,  as  noted  for  car- 
cinoma and  the  benign  neoplasms.  The  occurrence  is  intrinsically  rare, 
compared  with  other  new  growths  and  with  \'arious  other  urethral 
lesions.  AYomen  are  much  more  commonly  the  victims,  but  several 
well-established  cases  are  reported  in  the  male.  In  European  medical 
literature  the  first  accepted  notes  are  those  of  Hoening,^  on  fibro- 
sarcoma. Similar  reports  occur  every  few  years  up  to  the  present  time, 
including  those  of  Kizzoli-  and  Tillaux.^ 

Beuttner,'  Lejars'  and  Albarran*^  say  much  of  vesical  tumors,  but 
mention  no  urethral  tmnors  and  have  no  individual  case  reports. 

In  American  medical  literature  Hall  and  Frick^  have  described  a 
melanosarcoma  which  on  autopsy  gave  good  evidence  of  urethral 
source.  Later,  ]\Iark^  details  a  primary  urethral  sarcoma.  The  ure- 
throscopic  picture  is  sufficiently  suggestive  to  stand  as  probably  typical. 
A  24  F.  air-dilating  urethroscope  was  arrested  near  the  corona.  Dila- 
tation revealed  irregular  pale  polypoid  masses  scattered  along  the 
whole  wall  of  the  urethra.  Penetration  of  the  tube  to  the  scrotal 
urethra  scraped  off  several  of  the  masses,  whose  hemorrhage  delayed 
further  obser\'ation  for  a  few  days.  These  specimens  were  lost.  A 
second  examination  secured  other  specimens  from  the  deeper  anterior 

'  Berl.  kliii.  Wrhnschr.,   1869,  p.  55. 

■  Boll,  di  sci.  mod.  di  Bologna,  1873,  xvi,  145. 

3  Ann.  de  gyn.,  1889.  ^  Centralbl.  f.  Gynak.,  1894,  xxviii,  136. 

'  LcQons  dc  Chirurgie,  1895,  p.  598.  «  Medecine  operatoire,  1909. 

"  .lour.  Am.  Med.  Assn.,  1906,  xlvi,  1911. 

«  Tr.  Am.  Urol.  Assn.,  1908,  ii,  13;  1911,  v,  59;  Ann.  Surg.,  March,  1912. 


NONGONOCOCCAL  LE,SIONS  IN  URETIIUITIH  075 

urethra  up  to  the  membranous  canal.  A  cystoscofj,y  r(ivt;aled  marked 
contracture,  severe  cystitis  but  no  new  growth  within  the  bladder. 
The  lesion  was  a  sarcoma. 

For  the  diagnosis  there  is  nothing  absolute  except  the  microscope, 
but  a  sessile,  hard,  scarlike  growth  of  relatively  slow  advance  and  great 
infiltration  suggests  a  sarcoma.  If  the  prostate  is  in  a  similar  condition 
the  lesion  probably  is  secondary  and  contiguous. 

Carcinoma  and  sarcoma  are  the  growths  included  and  the  urethro- 
scope is  an  instrmnent  of  diagnosis  and  never  of  treatment.  The 
urologist  is  at  once  compelled  to  adopt  radical  ablation,  including  a 
large  part  of  the  surrounding  tissues.  In  modern  view  the  immediate 
application  of  intensive  .r-ray  treatment  to  the  open  wound  is  one  of 
the  most  potent  means  of  aftertreatment  to  postpone  or  prevent 
relapse.  Cure  must  in  these  dangerous  growths  mean  relief  from  relapse 
for  the  two  or  three  years  relied  on  in  general  surgery  as  a  cure. 

Urethral  Calculi. — The  forms  are  primary,  which  develop  within  the 
urethra  itself,  or  secondary,  which  arise  in  the  upper  urinary  organs 
and  passages  and  lodge  within  the  urethra  in  their  transit.  The 
primary  calculi  are  the  direct  product  of  obstruction,  stagnation, 
decomposition,  precipitation  and  formation  of  the  stones.  The  urine 
is  delayed  by  the  obstruction  and  its  solid  elements  mix  with  mucus 
after  precipitation  and  then  form  the  concretion.  They  are  therefore 
found  in  stricture,  fistula,  diverticulum  and  valves.  Like  other  calculi 
they  have  a  kernel  or  nucleus  usually  consisting  of  hardened  pus, 
detritus  and  epithelia  or  even  a  sjTnpexion  from  the  prostate  or  seminal 
vesicle  as  reported  by  Mark^  in  a  man,  forty-four  years  old,  who  had 
been  voiding  gelatinous  ovoid  masses  from  time  to  time  much  like  the 
sympexion  of  Robin.  An  elastic  stricture  contracted  and  pocketed  a 
stone  proximal  to  it.  This  was  discovered  and  removed  through  the 
urethroscope  and  found  to  be  a  shell  of  phosphates  containing,  a  dried 
kernel  which  was  undoubtedly  one  of  Robin's  bodies. 

The  bladder  during  lithiasis  may  become  encrusted  through  the 
precipitation  of  salts  upon  its  roughened  surface.  Chute^  has  described 
analogous  crusts  in  the  urethra,  formed  during  a  tuberculous  process. 
Foreign  bodies  have  been  retained  in  the  urethra  long  enough  to  become 
covered  with  precipitated  salts,  but  this  process  is  not  strictly  a 
lithiasis. 

The  secondary  stones  originate  in  the  kidneys,  ureters,  bladder  or 
prostate  and  in  their  passage  into  the  outer  world  are  held  up  in  the 
normal  or  pathologic  urethra.  In  site  they  may  be  partly  within  the 
bladder  and  urethra,  forming  the  vesicourethral  deposits,  or  partly 
within  the  prostate  and  the  urethra  comprising  the  prostatouretln-al 
concretions  or  wholly  within  the  urethra  making  the  truly  lu-ethral 
specimens.  The  author  has  never  seen  any  but  the  last  t\-pe  in  his  own 
practice.  Casper^  reports  a  case  of  stone  lying  within  the  prostate 
and  the  canal,  and  there  are  other  similar  case  records  by  noted  authors. 

1  Loc.  cit.,  p.  219.  2  Boston  Med.  Jour.,  1903,  cxlix,  361. 

3  Text-book  of  Genito-urinary  Diseases,  translated  by  Bonney,  1909,  ii,  386. 


676 


CRKrHROSCOPY 


The  autlior'  reported  a  ease  i)t'  urethral  lithiasis  in  a  Chinaman  wliose 
specunen  is  sliown  in  Fi^.  17i>,  and  a  case  of  nuiltii)le  jn'ostatie  lithiasis 
in  an  aged  sailor  who  passed  them  dmini:  urination.  The  specimens 
are  shown  in  Fig.  :^61. 

Treatment. — Stones  in  tlu'  hhidder  should  he  renu)N-ed  at  once,  as 
prevention  ot'  their  washing;  into  the  urethra  and  loduini;-  at  some  uoi  mal 
or  patholo<i;ieal  narrowinij  of  this  eanal.  Stones  which  are  located  both 
within  the  urethra  and  the  bladder  or  the  urethra  and  the  prostate 
will  require  cystotomy  or  ])rostat()my  for  their  renu)\al.  Stones  which 
inne  lodged  or  formed  within  the  urethra  ma>'  be  taken  away  only  by 
external  urethrotomy,  as  was  the  procedure  followed  by  the  author  in 
the  lu'ethral  stones  shown  in  Fig.  179.  The  immediate  aftertreatment 
of  all  these  operations  is  given  under  each  and  the  remote  aftercare  is 
sufficiently  discussed  imder  lithiasis  in  Chapters  Xl\',  X\'  and  XM, 
so  far  as  habit,  diet  and  medication  are  concerned,  .\tteution  to 
obstructions  of  the  urethra  is  noted  under  Stricture  in  ("ha])ter  \'ll. 


Fig.  179. — Urethral  calculus,  impacted  C(»phalad  to  an  anterior  urethral  stricture; 
removed  by  external  urethrotomy.      (Author's  case.) 


URETHROSCOPY  IN  THE  FEMALE. 

Significance. — In  woman,  as  in  man,  iu"ethroscop\-  is  most  important 
for  diagnosis,  treatment  and  ])r()phylaxis  in  both  the  ])ersonal  and  social 
sen.ses.  Similar  lesions  such  as  hypersensiti^■eness,  narrow  meatus  and 
stricture,  as  in  the  male,  nuiy  prevent  ready  examination  and  hence  the 
foretreatmeut  should  be  sufficient  to  accustom  the  patient  to  such 
manipulations.  The  distribution  of  lesions  begins  in  the  bladder  and 
ends  at  the  vestibule,  hence  a  proj^er  urethroscopy  shoidd  begin  with 
the  trigonum  of  the  bladder  and  end  at  the  meatus  exactly  as  in  the 
male. 

Instruments. — Xatm'all>'  the  same  five  cla.sses  are  available  as  stated 
in  the  historical  reca])itulation  of  the  science  in  the  male,  but  in  modern 
practice  the  same  choice  is  made  and  in  the  author's  opinion  should 
embrace  at  least  one  intrinsic  illumination,  water  dilatation,  magnify- 
ing, lateral  fenestrum,  operation  cystourethroscopc  and  one  intrinsic 
illumination  air-dilatation,  magnifying,  terminal  fenestrum,  operation 
urethroseoi)e.  The  same  accessories  in  instruments  and  medicaments 
are  available  as  in  the  oi)posite  sex  and  naturallx'  the  jjrocedure  does  not 


I  New  York  Med.  Jour.,  1913,  xc\-ii,  482. 


UliETH/iOSCOPY  IN  THE  FEMALE  677 

vary  between  the  sexes  in  the  n^rnote  and  immediate  prefja ration  of  the 
room,  patient  and  attendants. 

Technic. — Tlie  ])roeess  of  j)assinf^  tlie  urethj-oseope  in  vvoniar)  has 
four  steps:  insertion,  advancement,  depression  and  penetration. 

By  insertion  the  instrument  is  engaged  in  the  meatus  while  the  labia 
are  held  apart  and  this  is  followed  by  advancement  which  carries  the 
tip  to  the  neck  of  the  bladder,  which  is  usually  at  an  angle  with  the  axis 
of  the  urethra.  Depression  of  the  eyepiece  lirings  the  obturator  into 
the  line  of  the  neck  and  then  gentle  penetration  carries  it  through  the 
cut-off  muscle  into  the  bladder,  where  its  presence  is  shown  by  flux 
of  urine  when  the  pilot  is  withdrawn. 

The  identical  rules  of  gentleness,  patience  and  deliberation  must  be 
followed  in  the  female,  as  in  the  male,  and  these  cannot  be  too  much 
emphasized  in  practice. 

Anatomy  of  the  Urethra. — The  details  of  the  gross  and  minute  struc- 
ture of  the  female  urethra  have  been  mentioned  in  the  Chapter  on 
Gonococcal  Urethritis.  The  chief  elements  are  the  folds  of  the  muscle 
at  the  neck  of  the  bladder,  the  mucous  crypts,  Skene's  glands  and  the 
fact  that  the  mucosa  is  continuous  from  the  vestibule  to  the  bladder. 

Normal  Clinical  Features. 

Naturally  the  general  aspects  and  arrangement  are  not  unlike  the 
characteristics  of  the  deep  urethra  in  the  male,  of  wdiich  it  is  the  homo-  < 
logue.  We  find  therefore  that  delicacy  is  shown  by  the  thickness, 
freedom  by  the  attachment,  positive  redness  by  the  color,  definite 
fibrillation  by  the  vessels  and  elasticity  by  the  structure  as  a  whole. 
The  crypts  and  glands  are  both  moderately  abundant  and  the  laxity 
and  folds  are  more  numerous  than  in  the  male,  where  the  prostate  seems 
to  prevent  them.  Skene's  glands  are  homologous  with  Cowper's 
glands  in  man  and  are  equally  important. 

Special  Normal  Features  of  the  Urethral  Segments. 

The  female  canal  is  not  divisible  into  the  anatomical  portions,  as  the 
male,  but  in  clinical  urethroscopy  the  neck  of  the  bladder,  urethra  and 
meatus.  The  vesical  neck  is  usually  characterized  by  a  rounded  trans- 
verse eminence  which  forms  a  complete  collar  made  up  of  the  circular 
muscle  fibers  and  is  striated  by  numerous  axial  furrows  marking  the 
longitudinal  muscular  bundles.  The  appearance  is  tA'pical  of  the 
purse-string  arrangement  of  the  sphincter  muscle.  The  urethra  has 
soft,  lax,  mucous  membrane  containing  numerous  follicles  and  glands. 
The  meatus  is  a  dimple  and  contains  at  or  within  its  margin  the  two 
ducts  of  Skene's  glands,  one  on  each  side. 

Pathological  Clinical  Features  of  Urethroscopy. 

As  in  men,  so  in  w^omen,  one  must  distinguish  the  gonococcal  from  the 
nongonococcal  manifestations. 


678  URETHRO.'^COrY 

A.     Gonococcal  Lesions. 

In  the  process  aiul  results  of  goiiocoot-al  iiiHainination  imit-h  the  same 
changes  devek^p  in  both  the  fennUe  and  the  inak^  urethra.  The  ck'Hcacy 
of  tlie  mucosa  is  altered  or  lost  by  thic-kt'uing  and  the  attachment 
l>ecomes  more  dense.  Color  and  vascularit\-  are  greatly  heightciu'd  to 
a  li\iil  red  in  active  spots  or  decreased  to  a  paler  hue  where  infiltration 
has  reduced  the  blood  supply.  Altered  elasticity  is  manifested  along 
with  the  foregoing  proces.ses.  The  crypts,  glands  and  lacunji^  are  simi- 
larly atfected  so  that  one  sees  glands  in  which  an  acti\e  process  produces 
increased  secretion  and  those  in  which  atrophy  induces  dryness  and 
loss  of  the  normal  mucus.  The  laxity  and  folds  of  the  mucosa  may 
be  increased  or  decreased  and  its  gloss  abolished  by  loss  of  surface 
epithelia  or  cellular  substitution.  It  must  be  reuieuibered  that  all 
these  general  lesions  are  variously  related  to  each  other  and  scattered 
along  the  canal.  In  woman  the  urethra  is  so  short  that  the  variations 
and  groupings  are  less  manifest  than  in  the  male. 

Pathological  Special  Features  of  Urethroscopy. 

The  list  is  identical  with  the  one  given  for  the  male  in  the  nature  of 
the  identity  of  the  soil  and  of  the  infecting  organism.  There  are  there- 
fore seen  soft  infiltrations  and  bullous  edema.  Infected  glands  with 
ga])ing  ducts  iind  thick  discharge  or  no  discharge  occur  with  the  moist 
or  dry  form  of  glandular  compromise.  Cellular  change  is  represented 
by  granulation  tissue,  polypoid  masses,  exfoliation  and  ulcers.  Stricture 
formation  is  the  transition  from  soft  infiltration  likewise  through 
cellular  modification  and  often  results  in  deformity,  although  tight 
stricture  as  such  is  very  rare  in  woman.  More  minute  details  of  all 
these  lesions  are  given  under  the  subject  of  Chronic  Gonococcal 
Urethritis  on  page  264  or  under  Urethroscopy  in  the  Male  on  page  616. 

B.  Nongonococcal  Lesions. 

There  is  no  difference  in  the  varieties  and  significance  of  these  con- 
ditions between  the  two  sexes,  but  several  of  them  are  either  less  or 
more  common  in  women  than  in  men. 

Anatomical  Abnormalities  in  the  form  of  valves  and  diverticula  are 
much  less  frequently  encountered  in  women. 

Special  Inflammations  and  Infections  have  about  the  same 
occurrence  and  im])ortance  and  catalogue  the  same  lesions,  notably 
urethritis  of  catarrhal,  suppurative,  herpetic,  tuberculous,  chancroidal 
and  syphilitic  origin.  They  do  not  differ  in  any  essential  clinical  detail 
from  the  descriptions  already  stated  for  them  in  the  male,  with  due 
allowance  for  anatomical  arrangement. 

Neoplastic  urethritis  is  the  first  to  show  differences  although  the 
essential  subdivisions  into  primary  and  secondary,  benign  and  malig- 
nant growths  must  be  followed.    The  frequency  is  greater  in  women 


URETHROSCOPY  IN  THE  FEMALE  079 

than  in  men  in  accordance  with  the  law  of  all  ii(;(Ji>l;i,sms.  Secondary 
growths  are  most  common  of  all  through  contiguity  of  oi-gans  commonly 
attacked — uterus,  vagina  and  bladder. 

A.  Benign  Neoplasms. — Under  this  heading  are  couiprised  the  same 
growths  as  just  noted  in  the  male. 

Papilloma. — Papilloma  has  the  same  clinical  aspect  as  in  man  and 
occurs  about  the  folds  of  the  vulva  and  the  surface  of  the  vestibule. 
Endourethral  specimens  are  often  associated  and  are  easily  recognized 
through  the  urethroscope. 

Polypus. — Counting  the  vascular  polypi  as  the  chief  form,  polypus 
is  much  more  common  in  woman  than  in  man,  but  on  the  other  hand, 
fibrous  polypi  are  by  no  means  uncommon  and  may  enlarge,  elongate 
their  pedicles  and  by  muscular  action  present  at  the  meatus  exactly  as 
uterine  polypi  appear  at  the  os  externum.  Their  clinical  characteristics 
are  the  same  as  those  seen  in  the  male  and  likewise  their  urethroscopic 
picture. 

Vascular  Polypus. — ^The  vascular  polypus  is  also  called  caruncle, 
irritable  caruncle  and  angioma.  It  is  the  most  common  of  all  polypoid 
urethral  growths,  including  both  sexes,  and  the  last  term  typifies  its 
nature.  As  already  stated,  it  is  rare  and  almost  inexplicable  in  the 
male,  as  its  basis  is  assumed  to  be  misplaced  erectile  tissue  in  woman, 
which  is  not  characteristic  of  the  female.  The  site  is  at  the  meatus  or 
near  the  meatus,  and  like  polypus  is  often  crowded  outward.  Its 
occurrence  is  a  connective  tissue  stroma  filled  with  tufts  of  capillaries, 
redundantly  innervated  and  covered  with  stratified  epithelium.  They 
usually  are  single,  but  may  be  multiple.  The  urethroscopic  picture 
is  typical  but  the  use  of  the  instrument  is  not  necessary  because  the 
naked  eye  will  make  the  diagnosis  on  everting  the  meatus.  They  are 
bright  red,  tender  and  soft  tufts  of  mucous  membrane,  bleed  easily 
and  are  either  sessile  or  pedunculated  in  their  attachment.  Their 
termination  rests  on  operative  removal  as  the  aggravation  of  urination 
and  intercourse  increases  their  size  and  symptoms. 

Varices. — On  account  of  the  erectile  sinuses  in  the  vulva  which 
may  themselves  become  varicosed  enlarged  venules  in  the  urethra, 
especially  around  the  meatus,  are  much  more  common  in  woman  than 
in  man.  The  influence  of  pregnancy  in  causing  extensive  distention 
and  infiltration  of  the  veins  is  another  factor  in  this  greater  frequency. 
The  diagnosis  is  usually  so  obvious  that  a  urethroscopy  is  unnecessary 
and,  indeed,  the  instrument  may  cause  bleeding  of  obstinate  type  from 
such  veins. 

B.  Malignant  Neoplasms. — Carcinoma  and  sarcoma,  primary  and 
secondary  are  the  forms  recognized. 

Carcinoma. — The  frequency  of  cancer  in  and  about'  the  uterus, 
vagina  and  bladder  makes  secondary  lesions  much  the  more  com- 
mon, but  the  diagnosis  is  already  established  from  the  initial  focus  so 
that  urethroscopy  is  unnecessary,  with  the  sole  exception  of  some 
cases  of  vesical  cancer  originating  in  the  neck  of  the  bladder  and 
extending  into  the  urethra.    The  primary  growths  may  arise  at  any 


GSO  rRKTIIROSCOPY 

point  of  tilt'  imicosa  ;is  sitr  and  show  the  nrotliroscopic  pictures 
closcrihcd  for  tiie  niak'.    Natm-ally  tlioir  clinifal  course  is  the  same. 

Smriiina. — The  forms  are  the  same  as  tliose  enumerated  for  the  male 
and  the  lesion  is  nnich  more  connnon  in  woman,  according  to  Marks, 
in  the  work  already  cited.  Legucu,'  howexcr,  states  as  the  result  of 
inxestigation.  that  sarcoma  is  found  chiefly  in  women  during  adult 
life:  of  10  recorded  cases  only  2  appeared  in  women  seventeen  and 
twenty-two  years  old.  Legueu  contributed  no  i)ersonal  material. 
Ehrendorfer-  has  noted  a  well-founded  case.  The  diagnosis  is  usually 
estahlishfd  hy  ordinaiy  i)hysical  examination  as  a  large,  hard  mass 
hut  thert'  is  nothing  ))athognomonic  of  the  lesion.  rrethrosco])y  may 
furnish  additional  e\idence. 

Calculi. — Lithiasis  of  the  urinary  tract  is  decidedly  common  in  women, 
although  not  so  common  as  in  men.  Primary  stones  of  the  female 
urethra  are  practically  unknown  on  account  of  the  shortness,  dilata- 
bility  and  muscularity  of  the  canal.  Secondary  concretion  is  likewise 
\'ery  rare.  Finsterer''  has  produced  the  best  study  of  this  subject  with 
the  result  of  discovering  only  14  recorded  cases  in  literature.  Their 
symptoms,  course  and  diagnosis  would  be  much  the  same  as  in  the  male 
with  allowance  for  anatomical  distinctions.  The  recognition  of  the 
stones  may  be  made  with  a  i)robe  as  well  as  with  the  urethroscope. 

THERAPEUTIC  URETHROSCOPY. 

Varieties. — The  iiiHuence  of  the  sexes  is  not  a  great  one  because  many 
of  the  essential  chronic  lesions  occur  in  the  mucosa  of  men  and  women 
alike.  For  this  reason  both  the  male  and  the  female  are  implied  in 
the  foregoing  descriptions.  Of  greater  importance  are  the  differences 
between  the  gonococcal  and  the  nongonococcal  lesions.  The  former 
are  the  most  manifest  and  are  therefore  given  first  place  in  the  following 
paragraplis  as  the  typical  foci. 

Gonococcal  Lesions. — ^General  Principles. — It  should  always  be 
r(>nieml)ered  that  urethroscopy  is  only  associated  with  the  other 
methods  of  treatment  and  that  it  is  used  in  alternation  and  in  se(|uence 
with  such  other  methods.  This  viewpoint  is  always  implied  in  the 
ffjllowing  paragraphs. 

Management. — I'rinar^-  antiseptics  are  advisedly  given  as  prelimi- 
nary jjrecautions,  and  if  the  work  is  at  all  severe,  rest  in  bed  overnight 
is  a  wise  protection  against  hemorrhage  and  other  results.  Irrigation 
of  the  urethra  with  styptics  and  antisej)tics  after  the  instrument  is 
withdrawn  will  often  keep  down  immediate  distress  on  the  part  of  the 
patient.  The  best  is  nitrate  of  silver  in  strengths  of  1  in  2000  to  1  in 
.lOO,  with  preference  for  the  weaker  solutions,  relatively  larger  quanti- 
ties and  heat  to  toleration.  As  in  treatment  of  gonococcal  urethritis 
by  other  means,  nonstimulating  diet  and  the  drinking  of  much  water 

'  Traite  Chirurgical  d'Urologie,  Pari.s,  1910,  p.  97.5. 

2  Centr.  f.  GynJikol.,  1892,  xvi,  .321. 

3  Deutsch.  Zeitschr.  f.  Chir.,  1900,  Ixxxi,   140. 


THERAPEUTIC  URETHROSCOPY  081 

are  advisable.  Medicinal  measures  are  represented  \)\'  fontiniuitirMi 
as  need  may  require  of  the  dru^s  employed  during  otiici-  forms  of 
treatment. 

Methods. — As  in  the  treatment  of  urethral  h^sious  in  f^^eiieral,  so  in 
urethroscopy  the  details  ;ire  nono})erative  and  ojK'rativc.  This  (hs- 
tinction  means  that  through  the  urethroscope  ap])lieations  of  medica- 
ments may  be  made  as  well  as  operations  done,  but,  on  the  other  hand, 
urethroscopy  is  itself  operative  and  should  be  so  considered  in  all 
aspects  from  preparation  to  aftercare. 

No  matter  whether  drugs  are  applied  or  instruments  usefl  thrtjugh 
the  urethroscope  the  lesions  are  the  same  in  both  anterior  and  posterior 
portions  of  the  canal  and  conservative  gentle  measures  used  several 
times  are  much  more  safe  and  efficient  than  severe  treatment  used  once. 
The  vulnerability  of  the  mucosa  to  disease  and  to  medicinal  or  operative 
treatment  is  the  same,  which  means  that  anything  which  rlamages 
the  membrane  severely  may  damage  it  beyond  recovery  and  in  that 
sense  destruction  of  the  mucosa  should  be  very  cautiously  undertaken. 
In  the  use  of  the  d'Arsonval  high-frequency  current  and  the  Oudin 
high-frequency  current  a  special  cable  and  electrode  are  advisable, 
although  an  ordinarily  well-insulated  wire  will  often  serve  the  pur  - 
pose.    Among  the  special  electrodes  none  is  better  than  that  of  Bugbee, 

Nongonococcal  Lesions. — Principles  and  Management. — Nongono- 
coccal conditions  have  much  the  same  basis  and  indications  as  the 
gonococcal  with  due  respect  for  the  difference  in  the  underlying  infec- 
tions and  lesions.  The  frequency  of  catarrhal  reaction  associated  with 
these  nongonococcal  diseases  is  one  of  their  most  important  pecu- 
liarities. In  each  of  the  foregoing  descriptions  the  various  important 
features  are  already  noted. 

Methods. — The  medicinal  means  must  be  adapted  to  the  special 
form  of  infection.  The  urethroscopic  group  of  cases  are  necessarily 
chronic  in  their  manifestations  and  require  appropriate  attention. 
Notably  catarrhal,  suppurative  and  s\^hilitic  invasions  have  their 
particular  and  familiar  requirements  by  systemic  administration. 
Chancroid  requires  its  own  local  measures.  Each  such  method  of 
treatment  has  been  discussed  under  its  own  disease.  Surgery  is  applied 
to  the  vast  majority  of  these  cases  already  shown  in  each  pathological 
example. 


CHAPTER    XIII. 
CYSTOSCOPY. 

GENERAL  CONSIDERATIONS. 

Introduction.  Basic  Principles.  ~A  surgical  ])r()ce(lure  such  as 
cystoscopy  rests  on  crrtaiii  bases  wliicli  sIk.uKI  he  firmly  founded  in 
tlie  mind  of  the  student  and  l^cfjinner  before  lie  may  expect  to  make 
any  material  ])roiiress  or  reach  true  success.  These  l)asic  i)rincii)les 
will  first  enga|,'e  attention,  and  include  in  particular  the  general  indi- 
cations of  cystoscopy,  the  confirmations  of  cystoscopy,  the  special 
indications  of  cystoscopy,  the  laboratory  indications  of  cysto.scopy, 
the  miscellaneous  important  indications  of  eystoscoi)y,  the  contra- 
indications of  cystoscopy  and  other  urological  instrumentatitm  and 
the  case  records  in  urology. 

The  description  of  the  various  types  of  cystoscopy  and  the  discussion 
of  the  a])plication  of  cystosco])y  to  the  difierent  j)ath()logical  ])rocesses 
of  the  urogenital  tract  will  com])rise  the  sul)ject-matter  of  Chapters 
XIV,  XV,  XVI  and  XVII. 

General  Indications. — Advances  in  electricity  resulting  in  the  produc- 
tion of  exploring  instruments  in  many  of  the  arts  and  sciences  have 
given  medicine  the  urethrosco])e  and  cystoscope  and  many  other 
instruments  of  the  diagnostic  and  therapeutic  type,  such  as  the  rhino- 
scope,  laryngoscope,  auroscope,  proctoscope  and  the  like. 

Advances  in  objective  diagnosis  in  all  branches  of  medical  science 
have  reached  no  greater  progress  than  in  urology  through  urethros- 
copy and  cystoscopy  and  their  adjuvants — the  various  renal  tests 
and  radiography. 

The  urethroscope  is  the  instrument  of  objective  diagnosis  of  all  the 
organs  of  the  lower  urogenital  tract:  in  the  male,  the  urethra  and 
the  glands  and  ducts  adjoined  to  and  emptying  into  it,  namely — the 
prostate,  testicles,  seminal  vesicles  through  their  ejaculatory  ducts, 
Cowper's  glands  through  their  outlets  and  the  simple  and  complicated 
mucous  follicles;  and  in  the  female  the  urethroscope  is  of  value  in 
ex])loring  the  urethra,  which  in  woman  represents  as  much  of  the 
urethra  in  man  as  lies  above  the  outlets  of  the  sexual  glands  referred  to. 
In  children,  urethroscopy  is  practically  impossible. 

The  cystoscope  is  the  means  of  localization  of  lesions  of  the  intrinsic 
organs  of  the  urinary  group  which  include  the  bladder,  the  ureters 
and  the  kidneys  in  the  male  and  female,  in  both  the  adult  and,  with 
certain  restrictions,  the  child. 

The  various  organs  of  the  sexual  and  urinary  systems  are  not  only 
complex  and  refined  but  their  nervous  control,  centripetal  and  centri- 


GENERAL  CONSIDERATIONS  083 

fugal,  is  located  in  about  the  same  segment  of  tlic;  sjjiiuil  coid,  vvliieli 
accounts  for  the  close  relatiou  of  physiological  jiihI  pathoK^gical  mani- 
festations. The  many  tissues  of  these  organs  are  so  delicate  and  their 
structures  so  analogous  that  they  are  all  subject  to  inu(;}i  tlic  same 
types  and  degrees  of  disease.  The  physiologic  continuity  of  the  urinary 
apparatus  from  the  kidneys  to  the  urinary  meatus  in  f)oth  sexes  renders 
possible  direct  transmissicm  of  many  diseases  from  a  single  focus, 
distally  and  proximally,  until  the  whole  system  becomes  more  or  less 
involved.  Exactly  the  same  state  of  affairs  applies  in  the  sexual  organs, 
owing  to  continuity  between  the  urethra  of  the  male  and  the  prostate, 
seminal  vesicles,  vasa  deferentia  and  testicles,  and,  in  the  female, 
between  the  ovaries  and  the  vulva  through  the  tubes,  uterus  and 
vagina. 

The  readiness  with  which  a  single  focus  at  any  point  of  these  systems, 
especially  perhaps  the  urinary  system,  becomes  a  generalized  disease, 
renders  the  earliest  possible  diagnosis  of  its  nature  of  the  greatest 
importance  for  scientific  treatment.  For  example,  such  a  focus  of 
tuberculosis  in  one  kidney  may  be  transferred  through  the  urine  to 
the  ureter  and  bladder,  distally  and  then  proximally  through  the  other 
ureter  to  the  opposite  kidney,  then  again  by  way  of  the  urine  it  may 
locate  in  the  prostate  or  testicles.  That  these  infections  may,  of 
course,  also  travel  by  way  of  the  blood  and  lymphatic  currents,  must 
ever  be  remembered. 

Syndromes  or  symptom-groups  without  urethrocystoscopy  for 
careful  distinction  and  analysis  may  give  a  definite  diagnosis,  especially 
in  medical  disease  of  the  urogenital  tract.  Much  less  commonly  are 
they  of  avail  in  the  surgical  affections.  Exactly  the  same  comment  is 
true  concerning  syndromes  combined  only  with  urinalysis.  Urinalysis 
may  fail  because  its  physical,  chemical  and  bacterial  elements  rarely 
have  definite  bearing  on  their  sources  and  seats  in  very  exact  degree. 

General  Confirmations. — Although  diagnosis  in  urologj^  may  be 
established  by  urethroscopy  and  cystoscopy  combined  with  such 
cognate  procedures  as  urethral  catheterization  and  urinary  separa- 
tion, it  is  advisable  always  to  employ  such  confirming  elements  as  the 
subjective  and  objective  symptoms  and  signs,  urinalysis,  photography 
and  radiography. 

All  diagnosis  comprises  four  parts,  as  does  a  picture-frame.  One 
piece  is  a  detailed  subjective  history,  another  a  careful  physical  exami- 
nation, the  third  a  complete  laboratory  investigation  and  the  fourth 
the  results  of  treatment.  In  urology  these  parts  are  of  great  impor- 
tance, inasmuch  as  a  focal  diagnosis  rests  largely  upon  the  thoroughness 
with  which  each  of  these  elements  in  the  case  is  investigated. 

The  careful  subjective  history  must  have  respect  for  the  past  of  the 
patient;  that  is,  family  history,  former  general  history,  former  venereal 
history  and  former  urological  history. 

The  family  history  includes  the  age  and  health  if  living  and  age 
and  cause,  if  deceased,  of  father,  mother,  brothers  and  sisters  and 
own  children. 


684  CYsroscoPY 

Tlie  foriner  ])ers()n;il  histin'v  iiotos  ])ro\i()Us  illnesses,  eonstitiitioiial 
ami  infeetioiis,  esj)eeially  of  lieart.  liiii^s,  liver  ami  nervous  system; 
condition  and  course  of  health;  digestion,  as  to  appetite  and  bowels; 
nervous  system  respecting  sleep  and  capacity  for  work;  habits  in 
alcohol,  tobacco  and  food;  eti'ects  of  accidents  and  operations. 

The  former  sexual  history  respects  masturbation  in  onset,  se\erity 
and  duration;  first  intercourse;  subscciuent  intercourses  in  regularity, 
frequency,  desire  and  pleasure. 

Tlie  former  venereal  history  should  record  urethritis,  as  to  dates, 
duration,  complications  and  treatment  of  each  attack;  syphilis  con- 
cerning date  and  seat  of  chancre,  incubation,  severity  and  course  of 
symptoms,  kinds  and  length  of  treatment  and  results  to  date;  chan- 
croid, warts,  herpes,  psoriasis  and  eczema  are  all  of  less  im])ort- 
ancc. 

In  the  former  urological  liistory,  in  kidney  cases,  thorough  in(|uiry 
must  be  made  as  to  the  causes'  of  nephritis,  among  the  more  conunon 
of  which  are:  infection  (measles,  scarlatina,  typhoid  fever,  dij)htheria, 
smallpox,  chickenpox,  malaria,  pertussis,  mumps,  tonsillitis,  rheuma- 
tism, cholera,  pneumonia,  pleurisy,  erysipelas);  exi)osure  to  cold; 
toxic  agents  (turpentine,  cantharides,  potassium  chlorate,  i)henol); 
extensive  injury  or  disease  of  the  skin;  chronic  suppurative  disease 
(tuberculosis) ;  heredity;  alcoholic  habit;  overeating;  vocations  (chronic 
lead  and  phosphorus  poisoning);  gout  and  injuries  to  the  kidney. 

The. foregoing  catalogue  of  renal  cases  may  })e  subdivided  into  those 
involving  toxins,  congestions  and  heredity. 

1.  The  toxins  are  the  infection,  poison,  suppuration,  alcoholism, 
overeating,  vocation  and  gout  cases. 

2.  The  congestions  are  the  exposure,  cutaneous  injury  and  renal 
trauma  examples,  wliile 

3.  Heredity  is  the  third  group  singular  and  peculiar  to  itself. 
Where  albuminuria  is  present  its  causes  other  than  those  of  nephritis 

must  })e  investigated.  The  more  usual  of  these  are  com])rised  in  the 
following  classes  as  given  by  Butler:'  hemic  (scurvy,  leukemia,  puri)ura, 
anemia,  jaundice,  diabetes),  circulatory  disturbances  (chronic  cardiac 
or  pulmonary  disease,  pressure  upon  renal  vein),  neurotic  (apoplexy, 
tetanus,  migraine,  delirium  tremens,  Graves's  disease,  cephalic  injuries) , 
functional  (cyclic — following  a  hearty  proteid  intake,  following  cold 
bath  or  severe  exercise,  constipation),  renal  disease  (amyloid  and  fatty 
degeneration,  neoplasms,  suppurative  nephritis),  extrarenal  disease 
(pyelitis,  ureteritis,  cystitis,  urethritis,  ])rostatic  disease,  presence  of 
semen  in  urethra). 

The  foregoing  list  may  be  classified  again  into  two  groups: 

1.  Intrinsic,  proceeding  from  the  kidney  itself;  including  organic 
and  functional  renal  disease  as  stated,  and 

2.  Extrinsic,  arising  outside  the  kidney  itself,  embracing  the  hemic, 
circulatory,  neurotic  and  extrarenal  lesions,  as  enumerated  by  Butler. 

'  Osier:  The  Principles  and  Practice  of  Metlioinc,  lOKl,  viii  (adapted). 
2  The  Diagnostics  of  Internal  Medicine,  1909,  iii. 


(IKNIiliAL  aONHIDIillATIONH  685 

The  record  of  former  attacks  of  disease  of  tlic  Madder  will  coinijlete 
this  part  of  the  history. 

After  the  elements  in  the  past  history  have;  been  covered  as  thor- 
oughly as  the  general  aspect  of  the  case  warrajits,  the  pres(;nt  condition 
of  the  patient  demands  attention. 

Present  general,  venereal  and  urological  histories  must  theref(;r(;  he 
heard  and  recorded. 

As  a  rule  many  cases  for  urethroscopy  and  cystoscopy  present  a 
present  general  history  which  contains  little  of  interest  excepting 
chiefly  tuberculosis,  neoplasms  and  calculus. 

The  present  general  history  rnust  inquire  into  concomitant  condi- 
tions, chiefly  tuberculosis,  neoplasms  and  calculus  formation,  and 
pulmonary,  cardiac,  vascular  and  hepatic  lesions  which  are  so  usually 
associated  with  urological  conditions. 

The  present  venereal  and  urological  histories  usually  merge  more  or 
less.  We  are  interested  in  the  subjective  story  concerning  the  duration 
of  the  symptoms  and  their  main  facts.  The  "chief  complaint"  is  the 
best  possible  "lead"  and  must  be  particularly  inquired  into.  Then 
comes  the  function  of  urination,  its  hourly  increase  or  decrease,  by  day 
and  night,  changes  in  the  form,  size  and  force  of  the  stream,  increase 
or  decrease  of  quantity,  changes  in  the  nature  of  the  act,  urgency, 
control,  interruption,  obstruction,  suppression;  pains  in  the  kidney, 
ureter  and  bladder  zones;  pains  in  the  sexual  organs,  their  relation  to 
urination,  defecation  and  copulation,  rest  and  activity,  their  cause, 
frequency,  cause  of  increase  or  decrease,  constancy,  remission,  inter- 
mission, duration,  character;  directions  of  travel  and  points  of  refer- 
ence. 

Data  in  both  sexes  similar  to  those  concerning  pain  should  be  elicited 
for  urethral  discharges  and  for  blood  and  pus  before,  during  and  after 
urination  and  coitus,  and  in  women  for  vaginal  conditions  also.  Gravel 
or  deposit  in  the  urine  is  very  important. 

Disturbances  of  the  sexual  organs;  variations  in  desire,  ejaculations, 
orgasm  and  sensation;  in  women,  dyspareunia;  functional  disturb- 
ances, especially  of  the  nervous  system  and  of  the  gastrointestinal 
tract  all  have  their  bearing. 

Functional  disturbances  must  not  be  overlooked.  Those  of  the 
nervous  system  embrace  neuroses,  depression,  melancholia,  exaltation, 
hypochondria,  indifference,  irritability  and  sleep.  Functional  dis- 
order of  the  digestive  system  should  refer  to  the  stomach,  liver  and 
intestines.    Constipation  is  usually  very  important. 

Complete  phj^sical  examination  should  follow  "leads"  from  the 
body  at  large  and  from  the  urological  system  in  particular.  It  there- 
fore must  be  both  general  and  urological.  The  latter  should  include 
noninstrumental  and  instrumental  investigation. 

Physical  examination  should  always  employ  inspection,  palpation, 
mensuration,  percussion  and  auscultation  in  detail  and  must  include 
the  circulation,  heart,  arteries  and  veins,  the  lungs,  liver,  with  the 
balance  of  the  digestive  system  and  the  cerebrospinal  axis:  all  in 


6S6  CYSTOSCOPY 

essential  corroboration  of  urolo^ical  findings.  Blood  ])ressnre  and 
anemia  are  specially  important. 

The  positions  in  physical  examination  are  the  standard :  erect,  snpine, 
prone.  ri,s:ht  and  left  lateral,  stoopintj,  ,c;enufacial,  lithotomy  both 
normal  and  cxaij^crated.  and  Trcn<lclcnl)urj;'s.  The  stoo])intf  ])ostnre 
is  either  over  the  edjj;e  of  a  table,  as  for  rectal  examination,  or  su|)ported 
on  the  siM'iieon's  shoulders,  as  for  kidney  inAcstijjation.  Percussion 
ma>"  be  with  tlu'  Hii_<,n'rs  for  ordinary  work  or  with  the  fist  and  hand 
for  the  kidn(\\s. 

(\)m])leteurt)lo,uicalcxa  HI inatioiu-ni braces  sexual,  urethral  and  vesical 
details,  ascertainable  by  means  other^than  urethroscopy  and  cystoscopy. 

A  sexual  invcstigatioti  in  children  and  adults  varies  with  the  sex. 
In  male  subjects  the  penis,  scrotum,  testicles,  cords,  seminal  vesicles 
and  ])rostate,  especially  for  any  chanfi;es  in  size,  form  and  consistency, 
with  their  bearing  on  the  bladder  floor,  are  included.  In  female 
individuals  one  explores  the  vagina  for  tears,  ])articularly  of  the  ante- 
rior wall,  the  uterus  for  enlargement,  version,  displacement  and  descent, 
mobility  and  fixity,  and  its  annexa  for  enlargement,  inflannnation  and 
adhesions;  because  any  or  all  these  features  inflnence  ^'esical  conditions. 
Changes  in  the  vagina  appear  chiefly  on  the  floor;  alterations  in  the 
uterus  affect  the  fundus  excepting  in  descent;  while  affections  of  the 
annexa  show  themselves  usually  at  the  sides  of  the  bladder.  In  virgins 
anesthesia  is  required  for  vaginal  examinations,  to  which  rectal  explora- 
tion is  to  l>e  ])refcrrcd  when  ])ossible. 

A  urethral  invcstujation  implies  palpation  and  instrumentation,  with 
various  forms  of  catheter,  sound  and  ordinary  external  inspection  and 
internal  insj^ection  with  the  urethroscope  and  cystoscope. 

Small  soft-rubber  catheters  are  used  for  irrigation  of  the  urethra, 
for  isolating  specimen  discharges  from  the  anterior  and  posterior 
urethra,  for  distinguishing  pus  in  the  urine  of  urethral  from  pus  of 
vesicle  origin  as  in  the  author's^  seven-glass  test  or  Wolbarst  five-glass 
test  or  other  multiple  glass  tests.  Bougies-a-boule  or  ball-sounds 
fix  the  number,  location  and  diameter  of  strictures  of  both  endo- 
urethral  and  extraurethral  origin.  The  flexible  is  preferable  to  the 
metal  type  of  ball-sound.  Urethral  sounds  with  straight  shafts  and 
shafts  having  standard  or  Benique  curves,  supplement  the  findings 
with  the  bougies-a-boule.  Sounds  having  round  tips  are  to  be  chosen 
rather  than  those  having  conical  ])oints  for  locating  strictures,  while 
the  reverse  is  the  choice  for  dilating  them. 

The  urethroscope  is  of  value  for  the  end-to-end  study  of  the  mucosa 
for  sources  of  blood,  mucus,  pus  and  epithelia  in  the  urine,  not  of 
vesicle  origin.  The  straight  Buerger  cystourethroscope  permits  such 
examination  at  one  sitting. 

The  cystoscope  and  the  cystourethroscope  are  of  importance  in 
examining  the  sphincter  muscle  immediately  within  and  without  the 
bladder  as  a  possible  source  of  urgency,  tenesmus  or  blood. 

>  Pedersen,  V.  C:  Tr.  Am.  Urol,  .\s.sil,  191(),  x,  G1, 


GENERAL  CONSIDERATIONS  f)87 

The  physical  examination  of  the  bladder  is  an  adjuvant  oi  cystos- 
copy. Its  means  are  the  catheter,  stone  searcher,  sound,  .r-ray  and 
cystoscope. 

Silver,  soft-rubber  and  a  large  variety  of  soft,  woven,  varnished 
catheters  are  available  for  the  purpose.  The  important  special  forms 
are  the  single  elbow,  double  elbow,  olive  point  with  straight,  curved, 
single  elbow  and  double  elbow  shafts,  and  round  point  with  straight 
or  curved  shafts.  Any  of  these  types  may  be  cylindrical  or  flattened 
in  cross-section,  especially  the  elbow  catheters,  because  they  are 
employed  in  prostatic  conditions.  Silver  catheters  are  tunnelled  and 
grooved  at  the  tip,  round  pointed,  with  standard  and  Benique  curves 
but  have  largely  been  supplanted  by  the  foregoing  flexible  types  and 
by  the  irrigating  sounds  devised  by  the  writer  which  have  a  silver 
catheter  passing  through  the  shaft  to  the  base  of  the  groove  in  all 
types  and  sizes. 

The  stone-searchers  are  detailed  in  lithiasis  of  the  bladder.  The 
best  models  are  Thompson's  nonirrigating  type  and  the  author's^ 
irrigating  model.  The  sounds  are  of  the  flexible  and  steel  forms  which 
are  fully  discussed  in  the  Chapter  on  Stricture  of  the  Urethra  on  page 
375.  In  this  same  subject  likewise  are  given  the  full  details  of  their 
application  in  diagnosis  and  treatment.  The  steel  sounds  are  of  the 
standard  Benique  type,  with  or  without  irrigation.  The  author's^ 
irrigating  sounds  are  the  best  for  general  service. 

Radiography  is  of  manifest  value  and  its  application  will  be  con- 
sidered when  various  conditions  are  discussed  hereinafter. 

The  physical  conditions  of  the  bladder,  which  are  examined  by  the 
beforementioned  methods,  are  as  follows: 

The  catheter  shows  the  condition  of  the  vesical  urine,  independent 
of  the  urethral  urine,  the  capacity  and  irritability  and  the  amount  of 
residual  urine  of  the  bladder  as  in  enlarged  prostate. 

The  stone  searcher  is  an  aid  in  finding  vesical  calculi  when  the  cysto- 
scope cannot  be  introduced  and  the  .r-ray  is  not  available.  The 
author's  irrigating  type  of  stone  searcher  is  to  be  preferred.  Its  beak 
hooked  downward  over  an  enlarged  prostate,  or  slowly  passed  over 
and  along  it,  outlines  prostatic  enlargement,  and  in  some  cases  the 
location  and  size  of  tumor. 

The  sounds  are  available,  but  less  advisedly  so,  than  the  catheters 
for  indicating  bladder  capacity. 

The  author's  irrigating  sound  is  an  exception  to  this  dictum  and 
likewise  his  device^  for  using  gum-elastic  catheters  as  sheaths  upon 
lead-core  dilators  as  obturators,  for  exploring  the  urethra  and 
bladder. 

The  ureteral  and  renal  examination  is  performed  by  inspection, 
palpation,  percussion,  mensuration,  photography,  urinary  separators, 
the  cystoscope  with  the  ureteral  catheters,  the  functional  test  and  the 

1  Pedersen,  V.  C:  Med.  Rec,  February  19,  1910. 

2  Pedersen,  V.  C:  Ann.  Surg.,  October,  1909. 

3  Am.  Jour,  Urol.,  March,  1910,  also  Tr,  Am.  Urol.  Assn.,  1910,  iv,  92. 


688  CYSTOSCOPY 

polyuria  tests  of  tlir  kidneys.  Insijoction.  })aIi)atioii,  ])erc'ussi()n, 
nuMisuration  and  photof^rapliy  are  not  always  available,  as  many 
kidney  cases  do  not  give  objective  indications  under  them.  Advanced 
cases  of  tumor  and  hydronephrosis  do.  l^adio.e;rai)hy  is,  on  the  other 
hand,  indisjiensable  because  many  uretcrorenal  conditions  cannot  be 
diagnosticated  without  it. 

The  Luys  separator  is  of  cK)ubtful  value  when  directly  compared 
to  cystoscopy  with  ureteral  catheterization.  It  may  be  used  as  a 
corroborator  of  the  latter  in  an\"  case  or  as  a  substitute  when  catheteri- 
zation is  impossible.  It  should  be  included  in  the  office  e(iui])ment  of 
e\cry  urologist. 

General  Indications. — The  cystoscope  and  ureteral  catheterization, 
by  means  of  which  the  numerous  surgical  and  medical  conditions  of  the 
ureters  and  kidneys  are  cx])lored,  directly  as  an  instrumental  investi- 
gation and  indirectly  throuu'h  the  functional  and  i)()lyuria  tests,  is 
without  equivocation  the  instrument  of  choice.  The  details  of  its 
construction  and  medical  application  will  be  hereinafter  fully  dis- 
cu.ssed,  along  with  the  features  of  the  tests  alluded  to. 

Tlie  various  ureteral  and  renal  conditions  for  investigation  com])rise 
inflanunation,  foreign  bodies  and  neoplasms.  The  infhimmation  may 
be  bacterial,  as  pyogenic  and  tuberculous,  or  nonbacterial,  as  chronic 
interstitial.  The  foreign  bodies  embrace  precipitates  as  gravel  and 
calculus,  single  or  multiple,  small  or  large.  Xe()])lasms  embody  less 
commonly  nomnalignant  and  more  commonly  malignant,  forms,  the 
recognition  of  whose  earliest  possible  stage  is  of  supreme  moment. 

Special  Indications. — These  are  derived  from  disordered  urination, 
physical,  chemical  and  microsco])ic  urinalysis,  miscellaneous  symptoms 
and  correlation  with  surgical  work. 

The  disorders  of  urination  arc  chiefly  mechanical  and  include 
increased  frequency,  ischuria,  dysuria,  spasmodic  obstruction  or 
interruption  and  enuresis. 

Increased  frecjuency  of  micturition  is  the  most  common  and  ])romi- 
nent  cause  of  the  disordered  function,  and  originates  from  the  urethra, 
bladder,  kidney  and  ureter,  cerebrospinal  axis  and  systemic  diseases. 

The  urethral  causes  of  frequency  are  located  chiefly  in  the  posterior 
urethra  and  proceed  from  acute  and  chronic  inflammations,  particularly 
of  gonococcal  origin.  The  inflammation  induces  in  the  mucosa  of  the 
urethra  all  those  changes  which  it  does  in  vvery  other  mucosa  and 
which  lead  to  irritation  and  consequent  frequency.  These  changes 
are  commonly  localized  or  more  or  less  generalized  thickening  of  the 
mucosa  as  a  whole,  cicatrix  with  secondary  stricture,  cysts,  papillomata, 
folliculitis  of  the  urethral  and  prostatic  glands,  affections  of  the  colli- 
culus  and  ulceration. 

Frequency  of  micturition  is  due  to  vesical  conditions,  such  as  disease 
of  the  bladder  in  general,  hyj)cracidity  and  hypcralkalinit>'  of  the  urine, 
with  their  i)recipitates,  edema  and  swelling  of  the  trigone  and  outlet, 
inflammation  of  the  bladder  itself,  foreign  body  pathological  or  inten- 
tional, diverticula  and  neoplasms,  reflex  conditions  in  the  bladder 


GENERAL  (JONSIUE  HAT  IONS  689 

itself  excited  by  renal  and  ureteric;  infection  and  inflammation,  foreign 
body  and  tumor. 

Cystitis  and  trigonitis  may  be  localized,  disseminated,  or  general 
as  in  colon  bacilluria,  tyi)lioid  fever  and  tuberculosis,  provoking  fre- 
quency by  hyperemia  and  irritative  changes  in  the;  urine.  Foreign 
bodies  in  the  bladder,  such  as  the  crystals  of  hyperacid  and  hyper- 
alkaline  urine,  sand,  gravel  and  stone  of  decomposing  urine,  are  of 
pathological  origin;  while  various  objects,  such  as  hairpins,  fragments 
of  catheters  and  other  surgical  instruments,  are  intentionally  or  acci- 
dentally introduced.  All  such  adventitious  matter  acts  by  its  physical 
presence  to  traumatize  and  excoriate  the  mucosa  with  consequent  irri- 
tation and  frequency  of  urination.  Diverticula  of  the  bladder  act  as 
pockets  and  provoke  decomposition  and  irritation  in  the  same  cycle, 
as  just  alluded  to.  Neoplasms  of  the  bladder  both  benign  and  malign 
cause  this  symptom  by  acting  as  foreign  bodies  with  congestion, 
inflammation  and  necrosis;  Their  deformation  of  the  bladder  is  also  a 
factor.  The  prostate  provokes  frequency  of  urination  by  its  obstruc- 
tion, infection,  abscess  and  hypertrophy.  Its  neoplasm  acts  through 
elevation  of  the  bladder  floor,  and  pockets  behind  it,  hyperemia,  inter- 
ference with  evacuation  and  fermentation  of  urine.  The  uterus  and 
its  annexa  act  much  as  does  the  prostate  through  displacements,  ver- 
sions, descent,  enlargement  and  fixity.  Tears  of  the  perineum  and 
anterior  vaginal  wall  are  contributing  elements.  In  this  same  category 
should  be  placed  extravesical  tumors  of  bone,  muscle  or  intestine. 

Urinary  frequency  may  arise  from  the  upper  urinary  organs,  the 
kidneys  and  ureters,  through  the  increased  fluid  of  pyogenic  and  tuber- 
culous inflammation,  and  chronic  interstitial  nephritis.  Reflex  influ- 
ences bearing  on  this  symptom  arise  from  foreign  bodies,  such  as  sand, 
gravel  and  calculi  and  the  early  stages  of  neoplasm  in  the  kidney  or 
ureter  or  both. 

Systemic  diseases,  such  as  diabetes  mellitus  and  insipidus,  and  general 
conditions,  as  anemia  and  neurasthenia,  act  through  disturbed  nutri- 
tion and  increased  fluid  element  in  the  urine  in  ways  not  well  under- 
stood. 

Cerebrospinal  origin  of  frequency  may  be  functional,  inducing  neu- 
roses of  the  kidney  or  bladder,  or  organic  in  the  centers  of  the  lumbo- 
sacral region,  causing  changes  in  centripetal  or  centrifugal  impulses. 
Tabes  and  tumor  are  the  most  common. 

Retention  of  urination  or  ischuria  is  another  important  symptom 
in  the  function  of  urination  and  originates  in  causes  urethral,  peri- 
urethral, vesical  and  cerebrospinal  in  situation. 

The  urethra  may  cause  it  through  edema  of  inflammation  and 
trauma,  deformity  of  stricture,  closure  by  foreign  body,  pathological, 
accidental  or  intentional.  Periurethral  conditions  retain  the  urine 
through  pressure  as  in  abscess,  neoplasm,  prostatic  enlargement  either 
generalized  or  focalized  at  the  neck.  Vesical  causes  of  ischuria  arise  in 
atony  of  the  muscles,  the  paralysis  of  overdistention  and  the  mechan- 
ical disadvantages  of  deformity  of  the  bladder  floor.  Cerebrospinal 
44 


690  CYSTOSCOPY 

factors  affect  sensation  through  the  centrijx'tal  nerves  and  motion 
through  the  centrit'upil  nerx'es.  either  sxi'oi']^  hv'mii:  partially  or  totally 
paral.w.ed. 

Other  causes  of  tlisonlcr  of  tlu-  urinary  function  follow.  Dysuria  is 
painful  and  difficult  urination  and  affects  frequency  through  the  fear 
of  the  pain  and  the  mechanical  factor  in  the  difficulty.  Spasmodic 
interruj)tion  and  ()l)struction  of  m'ination  are  seen  in  the  "hall  and 
valve"  action  of  i)ediculate(l  enlargement  of  the  middle  lobe  of  the 
prostate  and  sometimes  of  foreign  bodies.  Enuresis  in  childhood  is 
either  diurnal  or  noctiu'iial,  almost  always  fimctional  and  usually 
indicates  lack  of  voluntary  inhibition.  Kniu'csis  in  the  adult  is  almost 
always  organic  and  l)rings  about  fretiuency  of  urination  through 
deformity  and  disease  of  the  outlet  and  wall  of  the  bladder,  overdis- 
tention  from  chronic  inflammation,  muscular  atony  or  hypertrophy 
and  the  paralyses  of  spinal  disease,  especially  tabes. 

Indications  in  urinalysis  ma>'  be  the  earliest  and  the  only  reasons 
for  this  procedure.  Hence  all  the  confirmations  of  cystoscopy  must 
be  carefully  applied  for  a  final  diagnosis.  The  physical  urinalysis 
concerns  chiefly  specific  gra^■ity,  turbidity  and  redness.  Specific 
gra^■ity  is  low  in  chronic  medical  inflammations  but  usually  high  in 
surgical  conditions  of  the  kidney,  owing  to  the  addition  of  blood  and 
pus.  Diabetes  mellitus  gives  advanced  but  insipidus  decreased  specific 
g^a^'ity.  Turbidity  may  be  due  to  phosphates  which  rapidly  dissipate 
upon  acidification,  or  due  to  carbonates  which  effervesce  in  the  pres- 
ence of  acid,  or  due  to  pus  which  coagulates  by  acid  and  i)recipitates, 
leaving  a  slightly  murky  supernatant  urine.  Chyle  behaves  in  much 
the  same  manner.  Redness  denotes  blood,  ^•a^ying  in  intensity  from 
the  faintest  tinge  requiring  microscopic  confirmation  to  the  color  of 
almost  pure  blood. 

Chemical  urinalysis  is  concerned  with  albuminuria  and  its  correla- 
tives albumosuria,  peptonuria,  nucleoalbuminuria  and  urea.  Pure 
albumin  is  apt  to  be  present  in  the  medical  conditions  of  the  kidneys 
and  more  or  less  associated  with  serum  albumin  and  serum  globulin, 
whereas  the  correlative  forms  are  apt  to  indicate  purulent  processes 
in  the  body  at  large  or  in  the  urinary  tract.  Nucleoalbumin  always 
means  focal  urogenital  pus.  Chemical  urinalysis  should  never  neglect 
urea  whose  normal  amount  is  2.0  per  cent,  by  weight,  which  is  open  to 
change  temporarily  under  nitrogenous  food  and  exercise  in  perfect 
health  from  the  normal  20  to  o5  grammes  (f  to  1|  ounces)  to  a  range 
from  the  minimum  of  10  grammes  to  the  maximum  100  grammes  in 
twenty-four  hours.  Concentrated  urine  of  febrile  conditions  usually 
shows  increased  urea,  while  it  decreases  in  kidney  disease,  unilaterally 
or  bilaterally,  temporarily  or  persistently',  j^rogressively  or  intermit- 
tently and  periodically*  or  constantly,  as  the  case  may  be. 

Microscopical  urinalysis  concerns  precipitates,  pus,  blood  and  casts. 
Acid  urine  causes  precipitation  of  uri?  acid,  urates,  oxalates,  hippuric 
acid,  leucin  and  tyrosin,  cystin  and  bilirubin.  Phosphates  may  appear 
in  feebly  acid  and  neutral  urine.    Alkaline  urine  throws  down  crystals 


GENE  UAL  CONSJDE  HAT  JONS  (391 

of  triple  phosphate,  calcium  f)h()S])hate,  basic;  magnesium  phosphate, 
granular  phosphate,  ammoniiun  urate  and  calcium  carbonate,  rarely 
in  pathological  conditions  leucin,  tyrosin  and  cystin.  Uric  acid,  urates 
and  phosphates  are  most  important  because  involved  in  the  formation 
of  calculi. 

Pyuria  or  pus  in  the  urine  may  be  macroscopic  or  microsco[)i(;  in 
quantity,  and  should  in  either  event  })e  studied  with  the  micToscope. 
It  may  arise  from  the  genital  or  the  urinary  organs.  In  the  former  the 
sources  of  supply  are  urethral,  prostatic  or  seminal  vesicular.  The 
importance  of  pus  in  the  urine  is  fully  developed  and  discussed  by  a 
previous  contribution  of  the  author.^  Like  all  other  urinary  symptoms 
it  should  be  traced  to  its  source  at  once  and  with  the  utmost  ac:iuracy. 
The  Wolbarst  five-glass  test  is  a  ready  and  accurate  means  of  distinc- 
tion.   The  writer  performs  this  test  in  the  following  manner: 

Under  strict  asepsis  and  antisepsis  of  the  operator,  instruments  and 
patient  so  far  as  practicable,  a  soft-rubber  12  to  16  Fr.  catheter  is 
passed  to  the  bulb  of  the  urethra  so  as  to  leave  free  evacuating  space 
around  it.  The  anterior  urethra  is  then  irrigated  with  warm  boric 
acid  or  normal  salt  solution  under  positivfe  but  judicious  pressure  wath  a 
150  c.c.  hand  syringe.  Gentle  urethral  massage  is  a  good  preliminary 
from  the  bulb  forward.  In  this  manner  Glass  I  is  secured,  showing 
the  contents  of  the  anterior  urethra.  Glass  II,  or  the  anterior  control 
glass,  is  prepared  by  repeating  this  process  and  is  ordinarily  perfectly 
clear,  except  perhaps  a  few  shreds  clinging  and  not  dislodged  before, 
such  as  frequently  appear  in  the  usual  Thompson  two-glass  test  as 
an  unimportant  error.  Glass  III,  or  the  bladder  urine,  is  prepared  by 
passing  the  soft-rubber  catheter  into  that  viscus.  If  clear  urine  is 
(irawn  we  know  that  the  pus  does  not  originate  in  the  urinary  organs, 
namely,  the  bladder,  ureters  and  kidneys.  Glass  IV,  or  the  posterior 
urethral  glass,  is  filled  by  having  the  patient  evacuate  the  clear  bladder 
urine,  carrying  with  it  the  contents  of  the  posterior  urethra  through 
the  previously  cleansed  anterior  channel.  Glass  V,  or  the  prostatic 
massage  glass,  is  obtained  by  having  the  patient  pass  the  balance  of  his 
urine  after  thorough  massage  of  the  prostate  and  stripping  of  the 
seminal  vesicles.  Glass  V  may  consist  of  boric  acid  or  normal  salt 
solution  if  the  quantity  of  urine  is  insufficient.  It  is  alw^ays  wise  to 
complete  this  test  by  irrigation  of  the  bladder  with  the  administration 
of  antiseptics,  particularly  if  active  infection,  like  tuberculosis  of  the 
prostate,  is  suspected. 

There  is  preference  for  the  seven-glass  test  of  the  author  because  it 
has  a  definite  bearing  on  secretions  of  the  prostate  and  seminal  vesicles 
in  disease.  The  details  of  the  performance  and  interpretation  of  this 
test  are  fully  discussed  under  the  subjects  of  Posterior  Chronic  Ure- 
thritis, Prostatitis  and  Seminal  Vesiculitis  on  pages  313  and  318.  They 
will  therefore  need  no  further  comment  here. 

Vesical  pyuria  may  be  temporary  and  declining,  or  persistent  and 
increasing  with  intermissions.    Its  causes  in  the  temporary  forms  may 

1  New  York  Med.  Jour.,  December  13,  1913. 


692  CYSTOSCOPY 

• 

be  direct  infection,  in  continuity  from  ])osteri()r  uivtliritis,  mvthro- 
oystitis  or  abscess  of  the  prostate;  or  may  be  by  accident  through 
bacteria  carried  into  the  bladder  op  instruments  (hu'ing  urethral 
ex])loration  or  treatment,  such  as  catheters,  sonnds,  urcthrosco])es  and 
cystoscopes;  or  may  i^e  due  to  inoculation  and  traumatism  during 
surgical  operations  on  the  bladder,  vagina  and  rectum;  or  may  very 
rarely  be  excited  by  the  administration  ot"  urinary  antiseptics.  Vesical 
pyuria  in  ])ersistcnt  and  ])rogrcssing  or  intermittent  degri^cs  arises  from 
infection  incident  to  calculi,  gravel,  new  growth,  sixH-iHc  organisms 
as  in  tuberculosis  and  decomposition  of  the  urine  in  deformity  of  the 
bladder  from  diverticula  and  prostatic  enlargement.  Renal  pyuria  of 
temi)orary  and  declining  degree  acc(Mn])anies  acute  infectious  diseases 
such  as  the  exanthemata,  is  connnonly  of  microscoj)ic  (luantity  and 
usually  disappears  early  or  late  in  the  convalescence.  Pus  in  the  kidney 
of  severe  and  persistent  degree  may  be  of  unilateral  or  bilateral  source 
from  diffuse  or  focalized  infections,  single  or  multijile  abscesses, 
cakuli,  neoplasm,  tirbercnlosis,  jn'clitis  or  ])yel()ne])hritis  or  from 
deformity  with  decomposition  of  the  urine  as  in  hydronephrosis.  Thus 
this  condition  becomes  with»relation  to  the  ureteric  pelvis  what  the 
hypertrophied  prostate  is  with  relation  to  the  bladder,  namely,  the 
cause  of  urinary  obstruction,  retention,  decomposition  and  infection. 
Hematuria  or  blood  in  the  urine  may  also  be  the  earliest  and  sole 
symptom  of  important  lesions,  therefore  the  fullest  possible  'corrobora- 
tion from  the  system  at  large  should  be  sought,  in  addition  to  regarding 
it  as  always  an  indication  for  cystoscopy.  Hematuria  may  be  incidental, 
that  is,  a])parently  not  associated  with  any  other  condition  or  symptom, 
or  it  may  be  distinctly  precedent  or  su})seciuent  to  a  more  or  less  definite 
or  indefinite  syndrome.  The  quantity  of  l)lood  may  be  practically 
microscopic  or  macroscopic  to  the  degree  of  virtual  purity,  chemically 
changed  or  unchanged  and  may  precede,  accompany  or  follow  urina- 
tion. These  facts  suggest  the  importance  of  careful  subjective  and 
ol)jective  scrutiny'  of  this  symptom.  Anemia  should  always  be  deter- 
mined and  recorded  if  the  bleeding  is  material  in  quantity  or  duration. 
The  sources  of  the  blood  are  urethral,  vesical  or  renal.  The  commonest 
causes  of  urethral  hematuria  are  traumatism  from  surgical  instruments, 
implements  employed  in  masturbation  and  severe,  especially  gono- 
coccal, infections.  Bacteriologic  investigation  and  careful  examination 
will  differentiate  these  conditions.  Hematuria  of  vesical  and  renal 
origin  is  usually  explained  in  much  the  same  way,  namely,  as  proceed- 
ing from  severe  infections  as  scarlet  fever,  sepsis  and  malaria;  or  from 
sudden  congestion  as  in  extensive  destruction  of  the  skin  in  scalds  and 
burns;  or  from  direct  visceral  damage  through  toxins  and  poisons; 
and  lastly  from  erosions  and  ulcers  situated  anywhere  in  kidney, 
bladder,  ureter  or  urethra,  inflammatory,  neoplastic  or  traumatic  in 
character  and  due  to  tuberculosis,  cancer,  hypernephroma  and  calculi. 
The  grave  significance  of  blood  in  the  urine  has  been  carefully  discussed 
by  the  author.^    Like  pus,  blood  proceeding  from  the  urinary  passages 

'  New  York  Med.  Jour.,  May  3,  1913. 


GENERAL  CON^lDEHATIONH  093 

must  be  diagnosed  as  to  its  source  as  quickly  and  accurately  as  possible, 
because  small  lesions  tunenabic  to  early  and  radical  cure  may  })leed 
profusely  and  then  renuiin  (juies(;ent  For  a.  long  time,  \vhil(;  the  other 
manifestations  of  the  disease  may  continue  their  ravages  unknown  to 
patient  or  urologist.  Tuberculosis  and  cancer  are  the  best  exam7)les 
of  this  dictum. 

The  corroboration  of  cystoscopy  obtained  through  radiography 
should  never  be  omitted  with  either  pyuria  or  hematuria  c)r  the 
indications  which  follow,  namely,  pain,  urinary  pyrexia,  surgical 
intervention  in  general  and  urinary  excretion . 

Other  Important  Indications. — Pain  in  urology  is  a  symptom  concern- 
ing which  four  factors  must  always  be  elicited:  "what,  why,  where  and 
whither."  Hence  we  should  know  the  pain  in  its  character,  location, 
point  of  maximum  intensity,  directions  and  area  of  reference,  cause, 
occurrence,  recurrence,  constancy,  remission,  intermission,  persistence, 
means  of  increase  and  decrease  and  accompaniments,  especially  blood, 
pus,  gravel  and  the  like. 

The  locations  of  pain  in  the  urogenital  tract  are  in  the  urethra  and 
penis,  generalized  in  prostatic  disease  or  limited  to  the  glans  in  vesical 
calculus  wherever  agitation  occurs;  or  in  the  bladder  by  severe  infec- 
tions, neoplasm  and  calculus;  or  in  the  ureter  alone,  kidney  alone, 
or  both,  through  the  same  three  conditions.  Rectal  examination, 
urethroscopy,  cystoscopy,  ureteral  catheterization  and  radiography 
will  usually  settle  the  diagnosis.  Dilatation  of  the  ureteric  pelvis 
may  be  cautiously  employed  in  selected  cases. 

Pain  and  similar  symptoms  referred  to  the  right  side  of  the  upper 
abdominal  region  require  consideration  of  the  following  sources: 
kidney  parenchyma,  kidney  pelvis  and  upper  ureter,  gall-bladder, 
gall  ducts,  and  pylorus  and  possibly  the  head  of  the  pancreas.  Cystos- 
copy, ureteral  catheterism  and  radiography  are  of  vast  importance 
in  such  a  diagnosis. 

Urinary  pyrexia  or  hyperpyrexia  (urethral  chill,  urethral  fever)  is 
the  sign  of  septic  absorption  either  from  immediate,  severe  invasion 
or  from  recrudescence  of  an  old  process.  It  indicates  cystoscopy  in 
order  to  determine  its  cause.  The  character  of  the  fever  is  a  sudden 
rise  to  104  degrees  Fahrenheit,  or  over,  sustained  for  few  or  many 
hours,  preceded  h^  one  or  more  very  severe  chills  and  followed  by  pro- 
nounced prostration  and  at  first  by  partial  or  total  anuria.  It  leads 
occasionally  to  exitus  in  the  late  stages  of  nephritis.  The  absorption 
may  occur  from  the  urethra  and  periurethral  structures  like  the  pros- 
tate and  seminal  vesicles  after  manipulation  and  instrumentation,  or 
may  occur  from  the  bladder  in  cystitis,  declining  with  it,  or  may  be 
local  within  the  ureters  and  kidneys  as  in  infections  and  calculi.  As  a 
rule  the  more  intense,  persistent  and  serious  forms  are  in  the  upper 
urinary  tract.  The  effect  on  the  urine  is  usually  aniu-ia  or  oliguria  or 
much  less  commonly  polyuria,  which  may  be  only  apparent  through 
reflex  increase  in  frequency  or  actual  as  determined  by  measure.  The 
presence  of  blood,  pus  and  gravel  is  very  important. 


694  CYSTOS(X)PY 

Surgical  Intervention.  Suri^Mcal  intt'r\onti()ii  is  ;m  indication  of 
cystoscopy  ill  disc owriuj,'  anatoinic-al  ahnormalitii's  siu'li  as  diver- 
ticula of  tlic  bladder,  absence  of  the  second  kidney,  presence  of  horse- 
shoe kidney,  and  of  coni])lete  or  incomplete  double  ureter;  and  in  out- 
linin.ii  the  patholoijical  relations  between  neo])lasnis,  also  inHanunatory 
deposits  and  the  ureters,  kidneys  and  bladder,  the  ])osition,  outlets 
and  courses  of  fistuhe  between  the  seminal  vc^siclcs,  ])rostate,  vaii;ina, 
rectum  .-iihI  bladder.  In  both  sexes  contraindications  to  surgical  work 
max  in  this  wa\  be  shown  or  \'aluable  ,i;iiidancc  in  the  stej)s  of  the 
operation  fuiMiishcd.  Mxploi-atorx'  c>"stosco])y  has  been  ])ractically 
abandoned  in  faxor  of  cystoscopy  with  added  mrthroscopy,  i)rocedures 
which  permit  nearl)y  examinations  of  the  bladder  as  a  whole,  in<'lu(ling 
the  neck,  and  the  lu'cteral  outlets  which  may  be  investigated  much  more 
thoroughly  and  intimately  than  with  the  naked  eye  through  a  woimd. 
After  cystosco])y  the  colla])sing  and  folding  of  the  bladder,  blood, 
imperfect  illumination,  all  limit  analysis  of  the  case  much  more  than 
urethrocystoscopy  t)rdinarily  does. 

Contraindications. — Like  all  other  urological  instrumentation  cysto- 
scopy rests  on  the  dangers  of  aggravation  of  sym]3toms  and  extension 
of  infection — either  into  other  parts  of  the  urogenital  tract  or  into  the 
system  at  large.  These  obstacles  may  be  classified  as  urethral,  vesical, 
ureteral,  renal,  prostatic  and  testicular.  Acute  inflammatory  condi- 
tions at  any  focus  of  the  tract  indicate  rest  and  freedom  from  inter- 
vention except  in  extraordinary  circumstances,  because  infectious 
elements  which  might  remain  at  the  original  point  are  readily  inocu- 
lated upon  other  points  not  only  by  the  instruments  themselves  but 
also  by  the  slight  traumatism  absolutely  una^'oidable,  which  opens 
the  door  to  extension. 

Cautions. — Variations  in  electrical  currents  recpiire  knowledge  on  the 
part  of  the  cystoscopist  as  to  the  cjuality  and  intensity  of  the  circuit 
in  the  building  where  the  case  is  to  be  explored.  The  commonest 
lighting  circuit  is  the  110  volt  direct  current  in  large  cities,  for  which 
the  standard  urethral  instrmnents  and  rheostats  are  adapted.  Many 
hotels  and  institutes  generate  their  own  direct  current  at  220  volts, 
which  requires  a  special  rheostat  of  resistance  lamps  to  reduce  the 
tension  to  110  volts.  Many  small  town?,  for  economy,  use  the  alter- 
nating current.  A  special  rheostat  is  necessary  to  con^'e^t  it  to  the 
direct  current,  110  volts,  otherwise  the  patient  will  be  greatly  pained, 
if  not  alarmed,  and  the  doctor  inconvenienced  both  by  restlessness  in 
the  patient  and  by  shocks  to  himself.  Fig.  191  illustrates  an  approved 
and  compact  form  of  such  rheostat. 

Case  Records. — Accuracy  of  work  and  interest  in  results  are  obtained 
by  rather  uniform  methods  or  recording  cases.  Lack  of  s[)ace  prevents 
full  discussion  of  this  matter  but  the  author's'  })revious  contribution 
contains  all  details.  There  are  necessary  at  least  forms  for  the  history, 
urinary  cards  and  analysis  reports. 

•  Pedorsen,  V.  C:  Acfuracy  and  Brevity  in  Office  Case  Records,  Tr.  Am.  Urol.  Assn., 
191.3,  vii,  163. 


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Urination  Cards. — The  iollo\vin<j  card  is  of  great  service  In  accurate 
record  of  urinary  symptoms  hy  the  ])atient.  It  will  be  noticed  that  it 
is  ruled  off  into  six  i)rimary  cohunns,  so  that  frequently  one  side  of  a 
card  will  cover  nearly  a  week.  Kach  column  is  sul)di\idcd  into  secon- 
dar\-  rulings  for  the  Hour  and  the  Notes  of  such  symi)tonis  as  i)ain, 
blood  and  ])ns.  for  exami)les.  It  is  well  to  h;i\c  the  ])atient  write  the 
date  at  the  top  of  each  colinnn  for  ( Icai'iicss  of  record,  thus  devoting 
a  coluiim  or  fraction  thereof  to  each  date.  It  is  the  ])ractice  of  the 
atithor  to  omit  the  use  of  these  cards  only  with  i)atients  who  might 
worry  imdnly  through  keeping  stich  a  record,  otherwise  they  are  very 
serviceable. 


VsBlcal 

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i 

Fig.   180. — Ui-ination  frequency  card.     The  patient  records  day,  hour  and  features  of 
each  evacuation,  as  a  definite  report  rather  than  as  a  supposition.    (Author's  Model.) 


Urinalysis  Charts. — The  following  charts  are  of  importance  in  such 
cases  as  tuberculosis  of  the  kidney  and  others  which  require  frequent 
analysis  and  careful  comparison.  By  suitable  spacing  a  half-dozen 
or  more  analyses  may  be  entered  on  one  sheet,  side  by  side,  so  that 
such  an  element  as  excretion  of  urea  may  be  read  along  one  line,  estab- 
lishing, as  it  were,  the  "urea  curve"  much  as  is  the  "efficiency  curve" 
in  an  engineer's  record.  Brevity  is  gained  by  the  use  of  a  key  and  sym- 
bols which  may  be  printed  at  the  bottom  or  top  of  each  sheet  such  as: 


Clear 

= 

cl. 

Acid 

= 

ac. 

Turbid 

= 

tb. 

Alkaline 

= 

alk. 

Bloody 

= 

bdy. 

Neutral 

= 

neut. 

Pussy 

= 

pus. 

Positive 

= 

+ 

Yellow 

= 

y. 

Strongly  positive 

= 

+  + 

lied 

= 

r. 

Very  strongly  positive 

= 

+  +  + 

Orange 

= 

o. 

Extreme 

= 

+  +  +  + 

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= 

urn. 

Absent 

= 

0 

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= 

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Doubtful 

= 

y 

Foul 

= 

foul. 

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=  < 

Very  faint  trace   = 

+  >>> 

Decreasing 

=  > 

Unchanged  = 

=  , 

GENERAL  CON, SIDE  HA  TIONH 


701 


The  date  of  the  analysis  is  inserted  at  the  toj)  of  each  folurnii  as 
an  aid  to  the  study  of  th(!  case. 

Functional  Diagnosis  Charts. — A  blank  form  for  such  records  is  also 
advisable,  such  as  that  which  the  author  has  found  most  convenient, 
as  follows.  It  is  available  both  when  the  ureters  are  catheterized  and 
when  the  Luys  urinary  separator  is  employed.  A  convenient  size  of 
the  record  sheet  has  been  found  to  be  8  x  10  inches. 


Urinalysis 


Casual  Spec 

24   Hour  Spec. 

LLILUIuli 

Crv«ah 

Physical  Analysis 

Quanl.ly 

Unc  Acid 

Color 
Odor 

Urates 
Oxalates 

Rtaction 
Spec.  Grav. 

riiospliates 
Hippuric  A 

Chcm  Analysis 

Leiic.n  &  Tyrosi 
Cystu, 

,       As.  HO, 
Phosphates 

fllkallne  Urine 

Acetic  Acid 
Carbonalc-s 

Tn.    Phophaic-s 

Accllc  Acl.l 
Sulphates 

l).,s.  Ma;     Pi.csi 

Ureo 

\  n  noiiium  Ural 
Calc     Carl.onatc 

_,    IlroniitcSoda 
'  Uric  Add 

Casts 
Hyaline 

Miircxiilc 
InJ/can 

tirai.tilar 

llcl-KCIO. 

Epithelial 

0.1..r 
lo.lofunn 

Blood 
Cvliiid.  Urates 

<ilucosc 

l-cNIing 

Cylind.  bacteria 
Bacterioloffy 

I'l.ii.yl-iiydr.izin 
CJuaiuity 

"bile 

Iodine 

Hiimiiig  HNO, 
Diazo-rcacllon 

Boiliuf.'AcctirA 

HNO, 
K-tcrro-cy.™ 

1      Tricliloracclic 
Q.uMily 

Serom  Albumen 
liaO  11  -• 

Settim  Olobulin 

Mag-Snlph 

.  Urinary  Sediments 

Urates 
Phosphates 

Tulljidity 
"*  Cliyle 

Fig.  181. — Author's  chart  for  consecutive  reports. 


General  Treatment  Chart. — The  variabihty  of  symptoms  in  severity 
and  of  the  means  of  treatment  makes  it  impossible  to  adopt  a  printed 
form,  but  a  standard  sheet  8x10  inches  may  be  ruled  in  blank  on  the 
following  plan  and  used  with  great  convenience  and  economy  of  time. 
A  column  an  inch  and  a  half  wide  is  ruled  down  the  left  margin  for  the 
insertion  of  prominent  symptoms.  Under  each  of  these  several  blank 
lines  are  left  for  the  noting  of  special  treatment  of  each  s\anptom. 
With  the  same  algebraic  symbols  employed  for  the  m-inalysis  charts 
the  course  of  each  symptom  is  noted  along  the  line  on  which  it  is 
written,  and  similarly  changes  in  a  given  treatment  are  noted  along 


702  CYSTOSCOPY 

the  respective  line  of  that  treatment.  As  an  exanii)li".  i^hosphaturia 
is  inserted  as  a  symptom  and  hydrochloric  acid  as  the  treatment 
thereof. 


Name Date 

Symptoms  :iiul  treatmcMit Datos  of  troatmciit 

Phosphaturia 

HCl  dil.  drops 

Such  arc  the  jirinciples  on  wliic  h  arc  based  the  general  indications, 
special  indications,  contraindications,  cautions  and  records  of  cystos- 
copy. If  the  beginner  follows  this  painstaking  and  thoroughgoing 
plan  he  will  find  that  his  knowledge  gains  in  accuracy  and  his  cases  in 
facility  m  classification  and  reference. 


HISTORY  OF  CYSTOSCOPY. 

The  Cystoscope. — Development. — A  fnll  epitome  of  this  subject  is 
that  of  Lewis.'  The  o])ti<'al  i)rinciples  of  the  cystoscope  are  referred 
to  works  on  ph>sics  and  to  special  details  in  mantifacturers'  catalogs. 
In  1S07,  Bozzini,  of  Frankfort,  combined  a  metal  tnbe  reflector  and 
candle  for  examining  the  bladder.  Brueck,  of  Breslau,  about  1867, 
applied  the  Incandescent  platinum  loop  for  "  stomatoscopy" — exam- 
ination of  body  ca^'ities.  In  1877  Xitze  applied  the  incandescent 
electric  light  to  the  first  real  cystoscope.  The  greatest  refinements 
and  im])rovements  in  the  instrtiment  have  been  made  in  America. 
Types. — The  subdivisions  respect  primary  and  secondary  forms. 
I.  Primarii  ]'arieties. — Respect  uses  and  are:  (a)  Examination. 

(6)  Catheterization 
(c)    0})eration. 
id)  Composite,  uni\er- 
sal  or  combined. 
XL  Secondary  Wirieties. — Involve  structure  and  are: 
1.  As  to  means  of  vision:   (a)  Telescopic,  having   trtie   optical   tele- 
scopes  with    magnification  of    direct 
lateral  anterograde  or  retrograde  fields 
and  inverted  or  erected  images'. 
(6)  Tubular,     haN'ing     naked     eye     vision 
through    the    sheath,    as    in    Kelly's 
cystoscope. 

2.  As  to  source  of  light:  («)  Extrinsic,  having  lamp  and  head  mirror. 

(6)   Intrinsic,  having  lamp  integral  with  the 
instrtnncnt. 

3.  As  to  object  in  field:  (a)  Inverting,  having  image  reversed. 

(6)  Erecting,  having   image  as  related   to 
the  bladder. 

»  Trans.  Am.  Urol.  Assd.,  I'JOS,  ii,  216. 


HI  STORY  OF  CYSTOSCOI'Y  TO.'i 

4.  As  to  position  of  field :  (a)  Direct  or   axial,  having    field  directly 

before  the  observer. 
(6)   Indirect  or  lateral,  presenting  field  at 
right  angles  to  the  axis  of  the  instru- 
ment. 

(c)  Retroversion     or    retrograde,     viewing 

field  between  the  lamp  and  observer. 

(d)  Anterovision  or  anterograde,  embracing 

field  beyond  the  lamp. 

5.  As  to  preparation  of  field :  (a)  Nondistending,    without   means    of 

filling  bladder  except  by  catheter. 

(6)   Distending,  with  air  or  fluid  through 

inlet  but  without  separate  outlet. 

(c)   Irrigating,  having  inlet  and  outlet 

faucets. 

Optical  Principles. — Telescopic  cystoscopes  have  these  characters. 
In  the  direct  or  axial  vision  instruments  there  is  a  straight  line  between 
the  object  and  the  eye,  and  magnification  and  definition  are  provided 
by  lenses  variously  arranged  and  adapted. 

In  the  indirect  or  lateral  vision  cystoscopes,  the  object  is  at  right 
angles  to  the  axis  of  the  telescope  and  its  image  is  transmitted  to  the 
eye  by  prisms  and  lenses  suitably  adjusted  and  combined. 

In  either  type  the  image  may  be  inverted  as  in  older  instruments, 
or  erected  as  in  later  models.    The  former  give  larger,  better  fields. 

Tubular  cystoscopes  are  of  the  Kelly  type,  without  lenses,  but  with 
axial  vision  directly  through  a  tube. 

Examination  Cystoscopes.  —  Construction.  —  Examination  only  is 
afforded  by  these  instruments.  The  best  models  are  of  American 
design,  consisting  of  a  sheath  with  small  incandescent  lamp  at  the 
beak,  electrical  equipment  and  switch,  irrigating  faucets  and  telescope 
separable  from  the  sheath.  Subcaliber  cystoscopes  for  children  and 
obstructed  cases  are  practically  the  only  instruments  of  this  t}^e. 

Practically  all  catheterization  and  composite  t\^es  have  at  least  two 
telescopes,  one  for  examination  and  the  other  for  other  uses. 

Catheterization  Cystoscopes. — Construction. — Again  the  best  models 
are  the  American  makes  which  were  the  first  to  introduce  double 
catheterization  telescopes.  In  addition  to  the  separable  sheath  and 
its  obturator  the  essential  is  a  telescope  of  reduced  caliber  and  size 
for  space  required  by  grooves  for  the  ureteral  catheters.  A  director, 
operated  with  a  thumb  screw  near  the  eye-piece,  is  placed  at  the  objec- 
tive lens  for  pointing  the  catheters  into  the  ureters.  Single  catlieteriz- 
ing  cystoscopes  are  essentially  subcaliber  instruments  in  which  tliere 
is  room  for  only  one  catheter.  They  are  available  for  children  and 
obstructed  urethrse. 

Operation  Cystoscopes. — Structure. — All  the  features  duplicate  those 
of  catheterization  instruments,  but  the  telescope  is  smaller  to  permit 
the  passage  of  such  instruments  as :  rongeurs,  scissors,  dilators,  snares 
and  electrodes. 


704  CYSTOSCOPY 

Composite  or  Universal  Cystoscopes. — Coiiftfniciion. — As  the  term 
iinplic^s,  t)ne  t(.'k'scc)])c  is  used  ti)  recoivc  all  forms  of  telescope,  axial 
and  lateral  field,  anterograde  and  retrograde  field  examination,  double 
eatheterizatiou  and  oi)eration  t\i)es. 

Avcrs,st)rir,s\ — These  are  the  instruments  stated  mider  operating 
eystoseo])es.  The  imiversal  cystoscope  of  Lewis'  is  one  of  the  most 
serviceable.  The  one  sheath  and  two  telescopes  furnish  direct  and 
indirect  observation;  direct  and  indirect  double  catheterization  up  to 
size  8  or  9;  direct  and  indirect  ai)})lication  of  all  intravesical  and 
intraureteral  instruments.  The  oi)erating  tcles('o])es  become  double 
catheterizing  telescopes  by  applying  a  double-barrelled  fin. 

All  vantages. — 1.  Adaptation  to  size  of  the  urethra;  (2)  sterilization 
by  boiling;  (3)  cleansing  of  the  ureteral  mouths  before  catheterization; 

(4)  adaptation  of  catheters  to  size  of  ureteral  mouths;  (5)  waxed-tip 
catheters  readily  employed;  (())  minor  operations  directly  done;  (7) 
lu-ethroscopy  during  withdrawal. 

DIsadrautages. — (1)  Extrinsic  illumination;  (2)  limitation  to  female; 
(3)  difficulty  of  genufacial  i)osture;  (4)  general  anesthesia  conunon; 

(5)  insufficiency  of  air  dilatation;  (())  field  reduced  to  diameter  of 
tubes;  (7)  greater  difficulty  of  use.  The  Eisner  and  Braasch  tubular 
cystoscopes  are  models  largely  on  Kelly 's.- 

Urinary  Segregators  or  Separators. — History. — The  development  of 
segregators  corres])onds  with  that  of  catheterization  cystoscopes. 

Types. — The  Harris-'  instrument  has  largely  been  replaced  by  that 
of  Luys,'  whose  components  are  omitted  because  so  familiar. 

The  composite  instrument  is  the  most  serviceable  because  it  com- 
bines all  four  common  uses  in  being  a  telescopic,  intrinsic  illuminating 
axial,  lateral,  retrograde  and  anterograde  vision  and  irrigating  model. 

Tubular  Cystoscopes. —  Types. — Kelly's  cystoscope  is  the  prototype, 
consisting  of  a  set  of  tubes,  obturators,  lamp,  head  mirror,  ureteral 
catheters,  and  other  accessory  instruments.  Its  features  in  situ  are 
clearly  shown  in  Fig.  19.S. 

Accessories. — The  usual  list  is  stated  under  operation  cystoscopes 
and  ])resented  In  Fig.  182.  Of  special  value  are  the  Lewis'^  ureteral 
dilator  and  fulgurating  blade  shown  in  Figs.  187  and  188. 

The  ureteral  dilator  illustrates  several  stages  of  use  in  stricture  and 
stone.  It  is  very  efficient  as  high  as  five  or  six  inches  up  the  ureter; 
beyond  this  limit  the  ordinary  bougies  are  safer. 

The  fourth  illustration  shows  its  traction  on  a  stone.  Older  tractors 
(bristle  probangs),  become  useless  after  one  or  two  trials.  The  Cun- 
ningham'' ureteral  catheter  is  of  little  service  as  a  telephonic  detector 
l)ut  much  as  a  dislodger. 


•  Am.  Jour.   Urol.,   1906,  ii,  598. 

■'  Kelly:  .Johns  Hopkin.s  Ho.sp.  Bull.,  189;^,  iv,  101. 

3  .Jour.  Am.  Med.  As.sn.,  1898,  iv,  274 

^  As.sn.  franc,  d'urol.  (1901)  1902,  v,  ,528. 

'•"  Personal  communication  to  author,  .July  19,  1917. 

«  Jour.  Am.  Med.  Assn.,  1909,  Hi,  p.  1331. 


mS'l'OUY  0I<'  CYHTOSCOI'Y 


705 


0 


Fig.  182. — Buerger  irrigating  catheterizing  and  operating  cystoscope.  (1)  concave 
sheath  and  obturator;  (2)  convex  sheath  and  telescope;  (3)  indirect  operating  and  cathe- 
terizing telescope;  (4)  patented  obturator;  (5)  irrigating  stop  cock;  (6)  large  rubber 
cystoscope  tips;  (7)  catheter  chp;  (8)  observation  telescope.  (Courtesy  of  Wappler 
Electric  Company.) 

45 


706 


CYSTOSCOPY 


P'iG.  183. — BuerKcr  siimle  cathotorizing  cystoscopc.  (1)  ohttirator;  (2)  convex  sheath; 
(3)  telesfope;  (4)  convex  sheath  and  telescope  ready  for  use.  (Courtesy  of  Wappler 
Electric  Company.) 


HISTORY  OF  CYSTOSCOPY 


701 


Fig.    1S4. — Acmi  subcaliber  cystoscopes.    (1)  concave  sheath;  (2)   obturating  telescope; 
(3)  convex  sheath.     (Courtesy  of  Wappler  Electric  Company.) 


ri)s 


CYSTOSCOI'Y 


I 


o 


I 


lO 


"t 


ro 


(N 


Fk;.  185. — Bransford  Lewis  universal  and  operating  cyfitoscope.  (1)  common  sheath 
with  obturator  in  place:  (2)  indirect  catheterizing  telescope;  (3)  direct  operating  or  single 
catheterizing  telescope;  (4)  catheter  clip;  (5)  operating  cystoscope  rubber  catheter  tip; 
(6)  plain  catheter  rubber  tip.      (Courtesy  Wappler  Electric  Company.) 


II I  STORY  OF  CYSTOSCOPY 


709 


Fig.  186.— Operating  forceps  and  snare.  (1)  Rongeur  forceps;  (2)  scissor  forceps;  (3) 
foreign  body  forceps;  (4)  Buerger's  snare.     (Courtesy  Wappler  Electric  Company.) 


7]() 


CYSTOSCOPY 


FiiTs.  ISS  tt)  UH)  show  tlu'  ;ii)i)li("iti()n  of  tlio  Lewis'  t'uli,MirMtiii>;-  hiade 
and  tolosfopc  to  c-ontrac-tuivs  of  tlir  \osical  nock  and  allied  conditions. 
It  is  eHVcti\c.  and  safer  than  the  ronueur  of  \'oun,u;''  and  similar  instru- 


I.,, 


'  1 


Fig.  1                           Fig.  2  Fu;.  3  Fu:.  4 

Fig.   187. — Ureteral  dilator.     (1)  Dilator  in  strictured  ureter.  (2)    Dilator  entering 

stricture.      (3)    Dilating   stricture.  (4)   Making  traction   on    a  stone  in    the    ureter. 
(Lewis.) 


Fig.   188. — Cautery  blade  and  telescope  for  use  in  cystoscope  sheath. 
1  Loc.  cit.  2  Loc  .cit. 


EQUIPMENT  FOR  CYSTOSCOPY 


11 


ments  which  often  cause  liciiKjrrhuge.     Lewis  states  that  this  blade 
causes  no  hemorrhage,  fever  or  reaction  and  leaves  the  patient  amhi  ilaiit. 


ComfCmi  AT  VESICAL  NECK 


ELECTRO- INCISION- 
THROUGH    CYSTOSCOPE 


Fig.   189. — Contracture  of  vesical  neck  (above)  and  application  of  cautery  blade  to  it 

(below) : 


Fig.   190. — Contracted  neck  before  cauterization  (left)  and  after  cauterization  (right). 
Figs.  188-190. — Fulgurating  blade  and  telescope.     (Lewis. i) 


EQUIPMENT  FOR  CYSTOSCOPY. 

Complete  equipment  includes  besides  the  stock  of  various  essential 
and  accessory  mstruments  their  storage,  care  and  sterilization,  prim- 
arily and  secondarily  the  selection  of  the  proper  outfit  for  a  given  case, 
which  naturally  respects  instructions  for  the  nurse  in  preparation  of  the 
room,  the  patient  and  the  supplies  for  the  cystoscopy. 

Accessories. — Accessory  instruments  of  the  equipment  for  cystos- 
copy embrace  the  lighting  apparatus,  the  irrigating  appliances,  the 
ureteral  catheters,  the  instruments  for  intravesical  treatment  and  the 
high-frequency  electrical  outfit. 

Sources  of  Light.— i\.pparatus  for  furnishing  light  is  either  a  controller 
for  reducing  the  standard  110  volt  direct  current;  or  a  transformer  for 
changing  the  alternating  to  the  direct  current  and  then  reducing  the 
latter;  or  a  set  of  dry  batteries,  wet  cells,  or  a  storage  battery:  all 
with  a  rheostat  for  management  of  the  current.  Thus  within  the  will 
of  the  operator  the  strength  of  current  passing  through  the  lamp  of  the 
cystoscope  is  adapted  to  its  capacity. 

'  Log.  cit. 


'12 


CYSTOSCOrY 


r(U'tal)l('  ;lry-crll  outfits  liaxc  bt'cn  sd  ])ri-l"e('ti'tl  as  to  constitute  a 
most  conw'uicnt  source  of  lijiiit  I'or  cases  in  w  hi<'li  it  is  not  |)()ssil)le  to 
use  (lyiuinio  current.  In  general,  liowexcr.  tlic  latter  is  by  far  the  best 
means  of  illumination,  with  the  aid  of  the  conti-ollcr  for  direct,  and  of 
the  transformer  for  the  alternating;  currents. 


Fig.  191. — Cystoscopic  portable  equipment.  The  canton  flannel  instrument  roll 
contains  a  selection  of  cystos(!opes,  cables,  guards  and  lubricant;  from  left  to  right  are 
the  catheter  and  syringe  boxes,  rheostat  and  lamp,  vesical  and  urethral  syringes  and 
boxes  containing  rubber  caps,  finger  stalls  and  pins;  behind  these  are  the  author's  eucaine 
and  alypin  anesthetic  lubricant,  styptic  powder  and  argentide  and  a  \n\e  of  gowns, 
leggings,  draperies  and  rubber  gloves.     (.Author's.) 


-^  ^ 


^'^A 


->ic 


Fii;.  192. — (  >  .>lu.~i(jjyii-  jjuitaljle  cquiijmcut.  All  supplies  .shown  in  the  foregoing 
illustration  have  been  rolled  in  sterilized  towels  and  sterilized  with  the  bag  itself  for 
several  hours  in  nascent  formaldehyde  gas.     (Author's.) 

Controllers  for  direct  current  are  made  by  various  manufacturers  so 
that  both  the  direct  and  alternating  systems  may  be  employed  inter- 
ehangeabl}'.  In  general  form  they  resemble  the  standard  lam])-socket 
with  a  body  about  four  inches  long.    On  this  is  wound  a  high-resistauee 


EQUIPMENT  FOR  C'YSTOSCO/'V  1\'4 

coil,  whence  a  sliiint  ciirn'iit  is  derived.  I)<ui};ci- (Iocs  iiol  resiill  tVorii 
short  eireuitiiij''  of  the  wires  coininj^  I'rotn  the  ■oiitroller;  hut  no  cont;!'! 
must  be  nuide  witii  any  nietjiJ  eonchietor  leiuhng-  to  llie  }i;ronnd,  sneh 
as  radiators  and  water  i)ipes.  As  one  of"  tlie  wires  from  the  main  is  ecjn- 
nected  to  the  ground,  the  one  touching  the  radiator  may  happen  to  \nt 
of  opposite  pohxrity  and  blow  out  a  fuse  or  damage  the  instrument. 

Wide  ranges  of  current  may  be  had  with  tliesc  controll(!rs.  ( isnall\' 
with  a  16  c.  p.  resistance  lamp  in  the  soc-ket  a  current  of  {).Vi  ampere 
and  from  0  to  25  volts  may  be  obtained  at  the  binding  posts;  and 
with  a  32  c.  p.  resistance  lamp  a  current  of  0.8  ampere  and  from  0  to 
about  40  volts  may  be  had.  A  rack  and  pinion  or  similar  movement 
increases  the  voltage  by  steps  of  a  third-part  of  one  volt  at  a  time. 
The  resistance  lamps  should  be  dark  in  order  to  shut  out  the  light  during 
examination  as  much  as  possible. 

The  transformer  for  alternating  current  should  be  ground-free  so 
that  the  possibility  of  shocking  the  patient  is  corrected.  There  are 
several  first-class  transformers  of  this  type  on  the  market.  Inasmuch 
as  they  require  no  resistance  lamp  they  are  specially  valuable  in  main- 
taining darkness  during  the  examination,  and  in  avoiding  breakage 
of  resistance  lamps,  which  immediately  cripples  the  operator  unless 
another  lamp  is  available. 

The  controller  base  of  the  author  is  valuable  for  private  house  work"^ 
in  that  the  long  cord  allows  one  to  connect  with  wall  socket  or  elec- 
trolier plug  at  a  great  distance  from  the  bed  or  table,  and  therefore  to 
use  only  the  standard  six  feet  of  small  twin  cable  between  the  controller 
and  the  cystoscope.  The  other  advantages  of  this  controller  base  are 
set  forth  in  the  original  article  as  follows : 

Irrigating  Appliances. — Irrigating  appliances  embrace  those  necessary 
for  the  nonirrigating  cystoscopes  and  those  for  the  irrigating  cysto- 
scopes.  At  least  in  the  United  States  few  really  modern  instru- 
ments do  not  provide  irrigation  at  all  times  during  the  cystoscopy. 
Should  this  form  be  the  only  one  available,  then  a  full  set  of  the 
various  types  and  sizes  of  soft-rubber  and  lisle-thread  catheters 
must  be  in  hand  for  selection  according  to  the  case.  With  the  irri- 
gating cystoscopes  a  good  hand-syringe  of  about  150  c.c.  capacity 
and  a  rubber  connecting  tube  about  4  feet  long  as  a  link  between 
the  cystoscope  and  the  syringe  are  necessary.  A  rubber  cap  for 
the  syringe  is  convenient  for  making  watertight  the  joint  between 
syringe  and  sheath  when  it  is  necessary  to  flush  out  the  bladder  actively 
with  the  telescope  out.  In  office  work  an  irrigating  jar  may  be  the 
source  of  water  supply,  but  is  not  so  good  as  the  hand  syringe  in  the 
hand  of  an  assistant,  which  permits  appreciation  of  the  reaction  of  the 
bladder  under  distention;  whereas  the  pressure  of  water  from  the  irri- 
gating jar  is  ''dead"  or  more  or  less  indeterminate  to  the  operator. 

Ureteral  catheters  are  at  the  present  time  of  one  appro^'ed  t^■pe  deter- 
mined by  the  tip,  which  instead  of  being  conical  or  olive  as  formerly, 

1  Jour.  Am.  Med.  Assn.,  1913,  Ix,  p.  182. 


714  CYSTOSCOPY 

is  now  rounded  ;md  cut  (•l)li(|ut'l\'  tor  tlio  end  opiMiiuji,  at  tlic  i^xpcnsc  of 
al)out  a  halt'-dianu'tiT  and  a  lialt'-(rutiuu'tt>r  of  k'U<:;th.  Ojjposito  this 
end  opt'uin<j,  and  occupying  al)out  thr  otlicr  half  of  the  first  crntiniotor, 
is  the  first  hitoral  opening;  while  the  seeonil  lateral  opening  is  opposite 
the  first  and  in  line  with  tiie  end  opening,  and  occupies  the  second  half 
of  the  second  centimeter.  Thus  the  three  o])enings  are  liiuits  of  the 
first  two  centimeters  of  length  and  spaced  about  a  half-centimeter 
apart.  Ireteral  catheters  are  made  of  woven  silk  or  lisle  thread  with 
carefully  varnished  surface  and  with  the  centimeters  of  length  shown 
by  yellow  and  black  or  yellow  and  red  stripes,  each  a  centimeter  wide. 
The  luuuber  of  centimeters  of  length  introduced  into  the  ureter  is 
sometimes  shown  by  small  stripes  spaced  as  follows:  one  narrow  stripe 
at  five  centimeters,  two  at  ten,  three  at  fifteen,  and  four  at  twenty 
centimeters;  one  wide  stripe  at  twenty-five,  one  narrow  at  thirty,  two 
narrow  at  thirty-fiAC  and  three  narrow  stripes  at  forty  centimeters. 
Thus  it  will  be  seen  that  all  the  stripes  are  narrow  excepting  that  at 
t\venty-fi\e  centuneters,  so  that  one  may  easily  know  the  distance 
above  or  below  that  figure  at  which  the  tip  of  the  instrument  lies.  The 
proximal  ends  of  most  catheters  are  now  made  conical  to  receive  a 
syringe  nozzle  conveniently;  but  such  conical  ends  prevent  withdrawal 
of  the  cystosc()i)e,  leaving  the  catheters  in  place;  hence  it  is  l^etter  to 
cut  them  oft'  and  connect  the  catheters  with  an  aspirating  needle 
deprived  of  its  point  and  fitting  tightly  into  the  caliber  of  the  catheter. 

Special  in-eteral  catheters  are  varnished  so  as  to  be  opaque  to  the 
.T-ray.  These  are  known  as  shadow  or  .r-ray  catheters  and  have  a 
very  great  advantage  in  that  the  opacity  obviates  the  necessity  of 
passing  wire  stilettes  through  the  catheters  which  is  at  once  painful 
and  somewhat  dangerous  to  the  patient. 

Another  special  form  of  ureteral  catheter  is  the  stone-searching  or 
telephonic  catheter  consisting  of  a  wire  with  a  conical  head  about 
5  F.  in  diameter  forming  the  tip  of  a  size  3  F.  catheter;  so  that  the 
wire  passes  through  it  from  end  to  end  and  terminates  in  a  little  glass 
earpiece  designed  to  rest  in  the  ear  of  the  operator  and  make  it  possible 
to  hear  the  grating  of  the  metal  tip  upon  the  stone. 

A  good  series  of  catheters  for  the  expert  to  possess  is  one  each  of 
sizes  3  F.  to  7  F,  both  inclusive,  of  the  yellow  and  black  and  yellow  and 
red  standard  markings;  two  size  5  F.  a:-ray  catheters,  or  a  similarly 
full  set  of  them,  sizes  3  to  7  F.;  two  telephonic  catheters  size  5  F.;  and 
several  soft  phosphor  ])r()nze  wires  as  stilettes  when  needed.  Stilettes 
must  not  bind  within  the  caliber  of  the  catheters. 

The  instruments  for  intravesical  nonelectrical  treatment  have  been 
sufficiently  portrayed  in  the  preceding  pages  under  the  heading  of 
operation  cystoscopes,  with  the  exce])tion,  however,  of  one  serviceable 
instnunent,  the  McCarthy  ftexiblc  forceps.  It  consists  of  a  flexible 
coiled  wire  sheath  through  which  a  small  alligator  forceps  passes  to  the 
handle,  at  which  a  spring  thumb-attachment  permits  the  operator  to 
open  and  close  the  jaws.  The  handle  of  the  instrument  is  of  the  form 
standard  for  most  surgical  implements  and  is  placed  at  right  angles  to 


EQUIPMENT  FOR.  CYSTOSCOPY  715 

the  shaft,  from  whicli  it  is  (h-tjiclicd  by  two  tliiiiiil)  nuts.  A  siiuill 
thumb  nut  on  the  handle  itseh'  pc'rmits  the  jaws  to  he  held  closed  in  ;i 
given  position.  It  is  designed  for  use  ir)  the  Aemi  operating  and 
catheterizing  eystoseope  and  may  be  direeted  with  the  facility  of  an 
ordinary  ureteral  catheter.  Its  action  is  strong,  jjositive  and  satis- 
factory in  a  properly  chosen  lesion. 

Several  genuine  whalebone  filiform  guides,  two  feet  long,  size  3  to  4  F., 
should  be  in  the  armamentarium,  available  for  the  method  of  stone 
searching  described  by  Burton  Harris,  consisting  briefly  in  coating  the 
first  two  centimeters  with  melted  beeswax  and  resin,  winch  is  scratched 
by  contact  with  the  ureteral  stone.  The  technic  of  preparation  and 
use  will  be  detailed  on  page  839,  under  the  subject  of  ureteral  calculi. 

The  high-tension  electrical  machines  in  the  accessory  equipment 
for  cystoscopy  are  either  portable  or  stationary.  The  stationary 
machines  vary  in  strength  from  those  producing  the  standard  Oudin 
current  to  those  developing  the  Oudin,  the  d'Arsonval  and  other 
complex  currents  of  high  potentiality,  including  those  for  .r-ray  pho- 
tography. With  such  instruments  general  electric  therapeutics  may 
also  be  applied.  The  portable  high-tension  machines  consist  of  a 
rotary  transformer  or  motor  dynamo  in  one  box,  and  in  a  second  box 
the  various  devices  for  developing  and  controlling  the  Oudin  and 
d'Arsonval  currents.  Each  case  weighs  nearly  fifty  pounds  but  is, 
nevertheless,  manageable  for  a  strong  man.  All  ranges  of  ordinary 
cystoscopic  treatment  may  be  reached  with  this  portable  outfit  but 
it  is  not  suitable  for  electrotherapeutics  except  within  very  limited 
degrees. 

Storage. — The  equipment  for  cystoscopy  is  most  conveniently 
provided  for  by  a  suitable  instrument  cabinet  on  the  shelves  of  which 
are  classified  the  various  essential  and  accessory  instruments  and 
supplies.    The  cabinet  of  the  writer  is  arranged  as  follows: 

Shelf  I.     Dressings: 

Sterilized  cut  gauze. 

Sterilized  gauze  wipes. 

Sterilized  towels. 

Sterilized  special  towels. 

Rubber  gloves. 

Rubber  finger  stalls. 

Rubber  bands. 
Shelf  II.     Chemical  Supplies  and  Glassware: 

Special  glasses  and  specimen  bottles  for  urine. 

Graduates  in  full  assortment. 

Glass  urethral  syringes. 

Two  syringes  with  needles  for  intravenous  injection. 

Phenolsulphonephthalein. 

Indigo  carmine. 

Cocain  powders,  grain  1. 

Eucain  powders,  grain  1. 

Alypin  powders,  grains  5. 

Alypin  solutions,  2  per  cent,  and  4  per  cent. 

Sterile  olive  oil. 

Hemostatic  powders. 

Colorimeter  with  extra  glass  prism.  Hypodermatic  syringe. 

Colorimeter  card. 

Lubricants — Irish  moss  jelly.  Vaseline  and  Boroglyceride. 


716  CYSTOSCOPY 

SuKLK   III.      ('j/sliisroiHs  iiiul  I'ntlirosaiiHs: 

Otis'  Exaiiiinatioii  Cystoscoix'. 

Hiu'ruiT  ( 'ystiiscopi'  witli  ox:iiiiiii:itinn,  ri'ti(j;;r:ii.lc  ;iiiil  CHllu'liMisiii  li'loseopes. 

K.  Tililoii  Mrnwii  Din-ct   X'ision  ( 'atlicli'iism  ( "ystoscopo. 

Kolliii  Cabot  Direi't  N'isiuii  ( "allii'tt'iistu  (."ystoscopo. 

BuoPKor  Cystouret liroseopo. 

V.   C\   Podorsen's   Linlit  Carrier  anil   ManiiifyiiiK  Lous   for  ilio    Hucrnor  Cysto- 
iirotlirosfopo. 

Box  containing  extra  lamps,  liiniiinu  posts,  faucets,  dellectors.  grease,  pins,  etc., 
for  cystoscopes  and  urethroscopes. 

Knife,  curette,  probe,  scissors  and  applicators  for  vesical  and  ureteral  treatment. 

Rubber  guards  against  sphvsh  aiul  high-tension  short  circuit. 
Shelf  IV.     Accessorioi: 

Standard  tu'eteral  catheters,  .'•{  7  V.  inclusive. 

X-ray  ureteral  catheters,  .">  F. 

.Stone  searching  ureteral  catheters.  5  F. 

Rubl)er  catheters  in  full  assortment. 

Lisle-thread  catheters  in  full  assortment. 
•         Harris'  filiform  guides  and  wax; 

V.  C.  Pedersen's  rheostat  and  switchbaso. 

Hand  .sj-ringes — 251)  c.c,  150  c.c,  and  100  c.c.  capacity. 

Standartl  direct-current  controller  with  16  c.  p.  and  32  c.  p.  resistance  lamps. 

Alternating-current  transformer. 

Cables  for  cystoscopes  (duplicates). 

Cables  for  urethroscopes  (duplicates). 

Glass  immersion  jar. 
Shelf  V. 

Complete  outfit  for  saKarsaii  iiifra\'enous  injection.^. 

Surgical  basins. 

Dark  field  illuminator. 

Chismore  evacuation  tubes,  bottles  and  bulbs. 

Proctoscopes  with  electrical  equipment. 

Lithot  rites. 

Formaldehyde  generating  lamp. 

The  special  towels  spoken  of  above  measure  about  30  inches  long 
by  20  inches  wide.  Six  inches  from  one  end  a  buttonhole  about  2  inches 
long  is  worked  through  which  the  cystoscope  passes  into  the  urethra  of 
the  male  or  female  and  through  which  only  the  penis  projects.  The 
loose  part  of  the  towel  is  gathered  gently  around  the  genitals  and 
buttocks  of  the  patient,  thus  insuring  protection  against  contact  and  the 
disagreeable  odor  which  is  almost  invariably  present.  Privacy  for  the 
patient  is  also  secured  most  convenientl}'. 

The  rubber  guards  against  splashing  and  high-tension  short  circuits 
are  made  of  black  rubber  packing  about  an  eighth  of  an  inch  thick, 
4  inches  square,  through  the  center  of  which  a  hole  is  made — a  tight 
fit  for  the  cystoscope  or  loose  for  the  fulgurating  wire.  When  in  place 
this  guard  receives  any  unexpected  spurt  of  bladder  or  urethral  contents, 
thus  thoroughly  protecting  the  operator.  The  fulgurating  wire  passing 
through  one  of  these  guards  is  held  in  the  hands  of  the  operator's 
assistant,  or  sometimes  by  the  patient  himself  so  that  the  high-tension 
wire  is  not  touching  anywhere.  This  in  itself  prevents  short  circuiting. 
Likewise  at  times  contact  between  the  genitals  and  the  coupler  may 
cause  short  circuits  there,  which  are  prevented  by  having  such  a  guard 
o\'er  the  urethroscope  or  cystoscope. 

Tile  lamp  for  generating  formaldehyde  gas  is  of  the  stajidard  type 
and  housed  in  a  tin  box  without  the  cover  and  stood  on  end — thus 


EQUIPMENT  FOR  CYSTOSCOPY  717 

serving  as  a  protection  against  the  heat  of  the  lamp  which  might  crack 
glass  or  ignite  wooden  shelves.  The  practice  of  the  aiitlior  is  to  have 
this  lamp  generate  the  gas  whenever  the  cal)inet  has  heen  opened  for 
more  than  a  very  brief  moment.  Repeated  interrupted  sterilization  oi 
the  entire  contents  is  provided  for  in  this  manner  very  adequately. 

The  ureteral  catheters  may  be  stored  in  long  glass  tubes,  which  if 
corked  should  contain  one  or  two  formalin  wafers  for  incessant  steril- 
ization. Or  the  catheters  may  be  kept  coiled  in  boxes  of  sufficient  size, 
about  6  inches  square,  so  as  not  to  curve  the  catheters  too  sharply. 
If  the  boxes  are  kept  covered,  formalin  wafers  should  be  inside  also. 
The  urethral  catheters  had  best  be  kept  flat  on  the  shelves  subject  to 
air  drying  and  the  influence  of  the  formaldehyde.  The  matter  of  air 
drying  is  very  important  as  it  prevents  sweating  of  the  catheters  and 
consequent  deterioration.  The  author,  therefore,  prefers  not  to  cork 
or  cover  any  of  the  catheters  and  feels  that  boxes  for  ureteral  catheters 
have  the  advantage  over  tubes  of  permitting  more  ready  transportation. 

The  immersion  jar  named  among  the  accessories  is  an  ordinary  wide 
mouth  prune  jar  with  a  bridge  having  several  holes  through  which  the 
urethral  instrviments  are  suspended  in  a  fluid  antiseptic;  thus  the 
eyepieces  are  not  wet  and  the  hands  of  the  operator  are  kept  out  of 
such  inconvenient  media  as  5  per  cent,  carbolic  acid  water.  In  an 
emergency  a  pitcher  may  be  similarly  employed,  so  that  the  wooden 
bridge  is  the  real  essential. 

There  are  special  urological  instrument  cabinets  made  with  small 
sockets  around  the  wall  of  one  space  corresponding  with  the  general 
position  of  one  shelf.  In  these  sockets  are  suspended  the  various 
cystoscopes,  urethroscopes  and  other  instruments,  with  the  purpose  of 
affording  contact  of  the  formaldehyde  gas  with  the  entire  surface  of 
the  instrument  which  penetrates  the  body,  both  urethra  and  bladder, 
for  example.  This  is  an  attractive  refinement  but  not  an  essential;  a 
urethral  instrument  thoroughly  and  properly  cleansed  may  perfectly 
well  be  laid  on  a  shelf  for  action  of  formaldehyde. 

Sterilization  of  Equipment  for  Cystoscopy  is  absolutely  important 
and  must  be  carried  out  to  the  last  degree  of  care.  It  includes  not  only 
the  instruments  themselves  and  the  operative  field,  but  the  urmary 
excretions  so  far  as  possible  through  the  preliminary  administration 
of  any  efficient  urinary  antiseptic,  so  as  to  minimize  the  possibility  of 
growth  within  the  bladder  or  urethra  of  any  organisms  inadvertently 
introduced. 

The  means  of  sterilization  are  gaseous,  fluid  and  mechanical.  For- 
maldehyde is  the  best  gaseous  sterilizing  medium  and  is  most  con- 
veniently supplied  by  generating  lamps  and  wafers  within  cabinets 
and  other  instrument  containers.  All  parts  of  instruments  should  be 
separated,  none  assembled,  in  order  to  permit  full  contact  with  the 
gas. 

The  fluids  ordinarily  employed  for  sterilizing  cystoscopic  equipment 
are  95  per  cent,  carbolic  acid,  5  per  cent,  carbolic  acid,  95  per  cent, 
alcohol,  4  per  cent,  boric  acid  and  sterile  water.    It  should  be  remem- 


718  CYSTOSCOPY 

bered  that  concentratcHl  carliolicaciii  is  an  oily,  clinfiinji- fluid,  insoluhle 
in  cold  water,  but  soluble  in  alcohol,  with  which  it  shoidd  therefore  be 
washed  ott"  the  instruments  to  escape  its  caustic  ett'ect.  Alcohol  attacks 
the  \arnish  of  all  wo\en  instruments  and  sometimes  the  cement  used 
to  fix  lam])s,  lenses  and  ])risms,  hence  it  should  not  be  used  except  for 
mo])j)inu-  and  rinsinj;  them.  Whatever  chemical  is  em])l()yed  final 
immersion  in  j)lain  sterile  water  is  ach'iscd.  Acid  and  alkaline  media 
are  similar  to  alcohol  in  action. 

The  mechanical  sterilization  of  the  et|ui])ment  for  cystoscopy  varies 
with  metal  and  nonmetal  instruments.  The  metal  instruments,  includ- 
ing cystoscopes  and  urethroscopes,  should  be  taken  apart  so  that  their 
mechanical  and  optical  elements  may  be  sterilized  individually.  They 
should  be  first  subjected  to  a  stiff  brushing  with  green  soa])  and  water, 
and  all  blood,  ])us,  detritus  and  other  foreign  matter  carefully  removed 
to  avoid  coagidation  and  caking  through  the  gaseous  and  chemical 
agents.  Tubular  parts  of  instruments  should  be  flushed  with  water 
imder  ])ressure  and  carefully  swabbed  with  cotton  or  gauze  on  s])ecial 
a})])licators  or  with  pipe  cleaners — in  short,  they  deserve  the  same  care 
as  rifle  barrels.  If  the  tubular  ])ortions  do  not  carry  the  electrical  or 
optical  systems  they  may  be  lioiled  with  the  plain  instruments. 

All  moving  mechanical  parts  and  joints  should  be  lighth'  lubricated 
with  sterilized  oil  after  the  mechanical  cleansing  and  drying. 

The  electrical  and  optical  portions  of  urological  instruments  cannot 
be  boiled  or  treated  with  the  stronger  chemical  antiseptics.  They 
should,  therefore,  receive  stifT  brushing  with  soap  and  water,  then  with 
5  per  cent,  carbolic  acid  water,  next  flushed  imder  pressure  and  swabbed 
or  mopped  with  5  per  cent,  carbolic  acid  water.  After  which  excess  of 
water  should  be  shaken  off  and  the  surface  dried  as  much  as  possible 
and  finally,  without  assembling,  all  the  parts  should  be  shelved  and 
exposed  to  formaldehyde  gas. 

The  foregoing  details  are  available  for  cases  giving  the  operator 
control  of  his  own  time.  In  emergency  or  rush  cases,  however,  the 
folio  whig  details  are  serviceable:  thorough  mechanical  cleansing, 
boiling  of  all  possible  parts  for  five  minutes,  immersion  in  5  per  cent, 
carbolic  acid  water  for  ten  minutes,  followed  by  thorough  flushing  and 
rhising  with  95  per  cent,  alcohol  and  then  with  sterilized  water;  if 
preferred  they  may  be  bathed  in  95  per  cent,  carbolic  two  minutes, 
followed  by  the  same  treatment  with  alcohol  and  water  as  just  stated. 

The  catheters,  which  include  both  urethral  and  ureteral,  are  sterilized 
substantially  in  the  same  manner.  Hard  flushing  with  water  should 
be  em])loyed  to  remove  blood,  pus,  detritus  and  other  foreign  matter. 
If  the  case  has  been  infectious  syphonage  may  be  employed  for  ureteral 
catheters.  This  is  carried  out  as  follows:  Any  large  vessel  is  filled  with 
sterilized  water  and  the  catheter.s  suspended  over  its  edge  so  that  their 
eyes  just  clear  the  bottom;  they  are  then  sucked  full  of  water  with  a 
hand  syringe,  ])laced  in  the  proximal  end  which  hangs  over  a  receiving 
basin;  thus  slow  syphonage  drops  through  the  catheters  for  several 
hours,  soaking  them  clean.     Sterile  water  used  in  this  way  may  be 


EQUIPMENT  FOR  CYSTOSCOrY  719 

followed  up  by  mild  antisepticts  for  a  V)rief  period,  as  stronj^  ehemicals 
and  long  exposure  deteriorate  the  varnisli.  Five  or  1 0  per  cent,  formalin 
water  is  about  the  most  serviceable  for  this  purpose.  Formaldehyde 
gas  gives  the  final  touch. 

In  emergency  and  hurry  cases  on  the  same  day  ureteral  catheters 
should  be  soaked  in  sterile  water  for  ten  minutes  to  soften  any  adherent 
foreign  matter;  then  scrubbed  with  soap  and  a  stiff  brush  thoroughly; 
next  flushed  under  pressure  under  sterile  water;  which  is  followed  by 
either  10  per  cent,  formalin  or  5  per  cent,  carbolic  acid  water;  in  turn 
followed  by  sterile  water  again.  These  catheters  may  be  boiled  a  num- 
ber of  times  in  water  free  of  alkali,  provided  the  temperature  is  slowly 
raised  to  the  boiling  point.  If  they  are  plunged  suddenly  into  boiling 
water  the  varnished  surface  is  almost  immediately  spoiled.  It  is  worth 
repeating  that  alcohol,  acid  and  alkaline  mediums  also  damage  the 
varnish  materially. 

Rubber  catheters  and  other  rubber  goods  may  be  boiled  in  water 
free  of  acid  or  alkali,  after,  of  course,  thorough  cleansing  in  the  manner 
previously  suggested.  If  nitrate  of  silver  has  been  used  in  catheters 
these  should  never  be  boiled  with  metal  instruments  as  the  silver 
oxidizes  in  black  spots  upon  the  nickel  surface. 

Soft-rubber  catheters  are  apt  to  lose  all  rigidity  by  frequent  boiling. 
When  this  undue  softness  begins  to  appear  it  may  be  very  largely 
obviated  by  giving  the  catheters  a  "rest  cure"  which  consists  of  sub- 
stituting others  for  them  while  they  are  permitted  to  dry  thoroughly  in 
the  air  and  thus  resume  their  former  stability.  In  this  manner  the  life 
of  good  rubber  catheters  may  be  materially  prolonged. 

Lubricants.— Lubricants  in  the  equipment  for  cystoscopy  are 
selected  with  respect  to  the  instrmnents  and  the  mucous  surfaces. 
They  should  therefore  have  the  following  characteristics:  semifluidity, 
adherence,  lubrication,  antisepsis,  non-irritation,  water-solubility, 
transparency,  translucency,  chemical  stability.  Only  three  lubricants 
fulfil  all  these  requirements,  namely — sterilized  glycerin,  borogly- 
ceride  and  katheterpurin.  All  are  available  for  urethral,  vesical  and 
ureteral  lubrication.  The  writer  favors  boroglyceride  because  it  is 
pharmacopeal,  normally  antiseptic  and  universally  procurable.  The 
formula  for  katheterpurin  is  as  follows: 

Oxycyanide  of  mercury 3^  grains  0.21  grammes 

Glycerin 5 1  drams  22.00  grammes 

Tragacanth 46     grains  2.76  grammes 

Sterilized  distilled  water 3    ounces  93.00  grammes 

Sterilized  olive  oil  is  the  only  true  oil  aA'ailable  in  cystoscopic  work  and 
for  the  sole  purpose  of  instillation  into  the  ureter  above  an  impacted 
calculus,  in  the  hope  of  assisting  it  in  migrating  into  the  bladder. 

Greases  in  cystoscopy  are  of  little  service  as  they  do  not  fulfil  the 
foregoing  prerequisites.  Vaseline  is  best  for  finger  cots  during  rectal 
guidance  of  instruments  into  the  bladder. 


720  cYSToscory 

PREPARATION  FOR  CYSTOSCOPY. 

rroi)arati()ii  tor  cystoscopy  comprises  both  the  selection  of  the 
equipnieiit  for  a  given  case  and  the  pre])arnti()ii  of  the  room,  ])atient, 
essential  and  accessor^'  instrnnients. 

Preparation  of  the  Room  and  Patient  varies  in  accordanci^  with  the 
selection  of  otlitt',  hos])ital  or  honir  for  the  work  and  with  the  general 
character  and  symptoms  of  the  case.  As  a  rule  in  all  cases  possible  it 
is  well  to  give  the  patient  a  general  body  bath,  evacuation  of  the  bowels 
with  cathartics  and  enema,  as  a  loaded  rectum  renders  introduction 
and  inani])ulation  of  the  eystoscopc  difhcult  and  may  greatly  alter  the 
ai)i)earanc(>  of  the  bladder  Hoor.  Water  may  be  administered  freely, 
unless  contra  indicated,  as  a  stimulus  of  the  kidneys,  beginning  about  a 
half  hour  before  the  examination.  Drugs  are  inadvisable  as  they  may 
alter  the  chemical  constituents  of  the  urine;  urinary  antiseptics  are, 
however,  athantageous  as  a  ])re^■entive  against  infection  and  other 
untoward  results.  Changes  in  the  urine  before  and  after  their  adminis- 
tration may  readily  be  estimated. 

In  all  male  cases,  moreover,  the  patency  of  the  urethra  up  to  2()  F. 
shoidd  be  known  pro^•ided  such  procedures  as  vu'eteral  catheterism  are 
to  be  carried  out.  Otherwise  its  patency  up  to  13  F.  or  18  F.  shotdd  be 
known  for  acceptance  of  the  children's  sizes  of  simple  examination 
cystoscopes.  IMeatotomy  may  be  advisable.  General  information 
concerning  the  ])rostate  as  to  congestion,  infection,  neoplasm  and  hy])er- 
trophy  should  be  fixed  for  the  proper  selection  of  instruments  and 
treatment. 

In  female  patients  a  preliminary  vaginal  douche  is  both  convenient 
and  a  preventive  against  infection. 

In  all  possible  cases  a  twenty-four-hour  specimen  of  urine  sliould  be 
collected  and  analyzed  just  before  the  cystoscopy.  A  general  physical 
examination  is  also  advisable  in  order  to  discover  important  lesions  other 
than  those  of  the  urogenital  tract,  unless  such  facts  have  already  been 
su])])lied  by  the  family  physician.  Usually  great  nervousness  thus 
discovered  is  relieved  by  sedatives,  the  choice  being  bromids,  codein 
and  in  extreme  cases,  just  before  the  examination,  morphin  or  during  it 
a  general  anesthetic. 

With  some  experts  it  is  the  rule  to  examine  simple  cases  with  urine 
in  the  bladder  as  the  medium  of  distention,  which  requires  the  patient 
to  hold  his  urine  for  se\'eral  hours  previously.  The  writer  prefers 
clear  water  as  the  basis  of  distention  so  that  the  eye  becomes  accus- 
tomed to  one  medium  which  has  as  little  effect  as  possible  on  the  color 
of  the  mucous  memlmine.  The  urine  varies  so  widely  in  color  as  to 
materially  change  the  pictiu'c  at  times. 

The  difficidt  cases  for  cystoscopy  are  those  which  show  hemorrhage 
and  great  irritability  of  the  bladder.  They  require  rest  in  bed ;  for  the 
blood  such  means  as  adrenalin,  astringents  and  hemostatics;  and  for  the 
irritabilit\'  local  anesthetics  such  as  solution  of  al>pin  (2  to  4  per  cent.), 
retained  in  the  bladder,  or  eucain  and  cocain  applied  to  the  urethra, 


PREPARATION  FOR  CYSTOSCOPY 


721 


or  even  injected  into  the  sacnil  caiuil  for  "l)lockitig"  the  saeral  nerves. 
General  anesthetics  are  a  last  resort  in  these  cases.  Adrenalin  may  be 
of  benefit  by  internal  administration  for  hemorrhage. 

Pus  is  another  element  in  different  cases  which,  like  blood,  requires 
repeated  and  thorouji;!!  Hushing  and  irrigation  of  the  bladder  fVjr  its 
removal.  Excepting  when  the  bladder  is  highly  irritable  it  is  best  to 
continue  this  washing  until  the  return  is  absolutely  clear,  so  that  the 
mucous  membrane  will  be  as  clear  as  possible  to  inspection. 

In  all  cases  the  prerequisites  are  those  of  a  laparotomy  and  involve 
asepsis  of  the  room,  cystoscopist,  assistant  and  nurses,  equipment 
and  field. 


Fig.   193.- 


-Semidrawer  leggings.    The  free  access  to  the  sexual  organs,  perineum,  anus 
and  thighs  are  clearly  shown. 


Dressing  and  Draping  the  Patient  are  largely  matters  of  taste  for  the 
cystoscopist  or  training  of  the  nurse  in  charge.  The  "UTiter  finds  it 
very  convenient  to  dress  males  and  females  precisely  as  one  does  the 
latter  for  a  pelvic  operation.  Namely,  sterilized  large  bag  leggmgs  are 
slipped  o^'er  the  lower  extremities  and  extended  to  the  waistlme,  of 
46 


722  CYSTOSCOPY 

muslin  for  summer  and  flannel  for  winter  service.  In  addition  to  these, 
the  special  buttonholed  towel  previously  described  covers  the  abdomen 
and  lower  thorax,  with  the  opening  over  the  genitals  and  the  short  tail 
gathered  abmit  the  buttocks  and  anus.  Other  sterili/.ed  towels  may  be 
spread  over  the  leggings  if  desired.  In  the  foregoing  manner  as  much 
privacy  as  possible  and  practically  absolute  asepsis  are  secured. 

Cystoscopy  in  the  Professional  Office  differs  in  no  respect  from  that 
in  a  luis])iial  and  is  in  thr  oi'dinary  nature  of  things  the  connnonest 
manner  of  such  examinations.  In  fact,  it  is  hardly  fair  for  any  cysto- 
scopist  to  accept  the  responsibility  of  the  work  mdess  his  quarters  are 
as  complete  as  possible  in  equipment.  In  other  words,  his  facilities 
must  be  adequate  for  all  exigencies. 

It  is  probably  best  to  lun"e  a  separate  room  de\oted  to  this  and  other 
strictly  aseptic  work  so  that  the  room  itself  tends  to  aid  in  the  pre- 
vention of  infection.  No  plan  is  more  convenient  than  that  of  the  writer 
whose  office  floor  is  laid  out  in  four  rooms  respectively  devoted  to  con- 
sultation and  ])reliminary  examination,  cystoscopy  and  urethroscopy, 
and  the  remaining  two  to  ordinary  treatment  of  pus  cases.  This 
plan  is  the  means  of  saving  all  the  time  which  each  patient  devotes 
to  dressing  and  undressing — in  a  professional  day  readily  an  hour 
or  more. 

The  final  prerequisites  therefore  are  alike  in  office,  hospital  and 
home  cystoscopy:  asepsis,  antisepsis  and  sterilization.  These  are  best 
maintained  by  a  commodious  instrument  cabinet  in  which  everything 
possible  is  stored  and  subjected  to  repeated  interrupted  sterilization 
with  formaldehyde  gas. 

Floor  Plan. — The  floor  plan  for  office  cystoscopy  is  the  same  as  for 
hospital  work  and  is  fully  described  under  this  subject,  so  may  here  be 
dismissed  by  saying  that  on  the  right  of  the  operator  stand  the  nurse  and 
the  table  carrying,  within  easy  reach  of  the  nurse,  everything  for  which 
she  is  responsible  (for  example,  dressings,  linen,  jars,  basins,  irrigation 
outfit  and  the  like)  and  carrying  within  easy  access  to  the  operator  all 
details  for  his  probable  needs — such  as  the  equipments  for  illumination, 
examination,  ureteral  catheterization,  treatment  (instrumental,  elec- 
trical and  chemical).  On  the  left  of  the  operator  stands  the  assistant 
in  charge  of  such  instruments  as  the  nurse  cannot  properly  manage, 
also  on  a  table,  if  desired,  notably  the  fulguration  generator  and  con- 
trollers. The  \\Titer  prefers  to  have  his  assistant  rather  than  the  nurse 
take  charge  of  such  important  matters  as  the  specimens  duly  labeled 
in  their  various  glasses,  tubes  and  bottles,  and  of  the  local  anesthetics 
for  spinal  or  sacral,  vesical,  urethral  and  meatal  administration  as 
later  discussed  more  fully. 

One  sometimes  hears  the  statement  that  office  examinations  may 
decide  a  diagnosis  sufficiently  for  proceeding  with  the  detail  of  treat- 
ment and  need,  therefore,  not  be  as  formal  as  a  hospital  cystoscopy. 
This  is  certainly  not  true,  especially  if  kidney  conditions  are  even 
indirectly  suspected.  Such  will  indicate  inevitably  catheterism  of  the 
ureters,  the  efficiency  test  and  every  knoA^Ti  form  of  diagnosis  as  much 


PREPARATION  FOR  CYSTOtiCOPY  723 

in  the  office  and  home  as  in  the  hospital.  It  is  true  that  simple  inspec- 
tion in  the  office  or  anywhere  else  may  recognize  such  j^cneral  <:()n- 
ditions  of  the  bladder  as  foci  of  tuberculosis,  hemorrhage,  pus  and 
neoplasm  but  cannot  possibly  go  any  farther  than  this. 

The  other  details  of  office  cystoscopy  are  fully  discussed  in  the 
immediately  succeeding  paragraphs  dealing  with  this  class  of  work  in 
institutions. 

Cystoscopy  in  Hospitals  usually  meets  the  ideals  of  every  facility  for 
full  asepsis  and  antisepsis.  There  should  be  an  adjustable  table  for 
securing  the  proper  and  comfortable  position  of  the  patient,  a  capacious 
one  for  the  cystoscopes  and  accessories,  and  often  a  third  for  dress- 
ings if  it  is  thought  such  will  be  needed. 

Cystoscopic  Tables  are  numerous  and  vary  from  the  very  complex 
and  expensive  to  the  simple,  efficient  and  less  expensive.  The  late 
Dr.  F.  Tilden  Brown  devised  a  very  satisfactory  complex  table  with 
which  almost  any  known  surgical  position  may  be  obtained.  He  also 
devised  a  pair  of  adjustable  leg  supports  affording  many  of  the  simpler 
attitudes  of  the  limbs  and  attachable  to  the  ordinary  household  table. 

The  author  has  produced  a  very  complete  simple  table  w^hich  permits 
of  all  the  cystoscopic  and  several  of  the  more  important  surgical  pos- 
tures with  ease  and  rapidity.  One  of  its  particular  features  is  that  the 
leg  rests  may  be  attached  to  the  forward  legs  of  the  table  and  remain 
behind  when  the  pelvis  is  raised,  so  that  the  thighs  drop  gently  down- 
ward into  a  position  of  repose,  for  many  patients  far  more  easy  than 
the  lithotomy  position.  If  it  is  desirable  to  use  the  latter  position  the 
rests  may  be  attached  to  the  center  piece  of  the  table  and  moved  with 
it.  For  the  lithotomy  posture  one  of  the  most  convenient  leg  rests  is 
the  knee  crotch  holder  fitting  behind  the  flexure  of  the  knee  so  as  to 
support  both  the  thigh  and  the  leg  in  a  very  comfortable,  hollow 
receiver.  The  simple  foot  boards  about  14  by  4  inches  with  a  metal 
margin,  and  mounted  on  the  same  clutch  as  the  gynecological  footrest 
for  clamping  to  the  bars  of  the  table,  are  most  comfortable  in  that  the 
weight  of  the  limbs  rests  on  the  feet  as  wholes,  which  prevents  the 
ankle  clonus  and  other  tremor  often  seen  with  the  common  stirrups. 

Postures  for  Cystoscopy. — For  simple  rapid  inspection  of  the  bladder 
the  top  of  the  table  may  be  left  flat  and  the  patient  lies  supine  upon  it 
with  the  lower  extremities  extended  and  separated.  The  observer 
stands  at  the  side  and  stoops  until  his  eye  is  in  Ime  with  the  cystoscope 
— a  most  uncomfortable  position  for  him  but  a  very  easy  one  for  the 
patient. 

The  genufacial  posture  is  necessary  for  females  if  the  tubular  t%'pe  of 
cystoscope  such  as  Kelly's  and  Pryor's  is  to  be  used.  This  is  mani- 
festly a  most  difficult  attitude  for  the  patient  to  maintain  for  any  long 
period.  It  therefore  requires  a  general  anesthetic  and  artificial  suspen- 
sion of  the  patient  in  this  position  for  difficult  and  prolonged  investi- 
gation. 

The  general  posture  for  cystoscopy  preferred  by  the  writer  is  as 
follows:  the  pelvis  is  elevated  mitil  the  eyepiece  of  the  cystoscope  is 


724 


CYSTOSCOPY 


opposite  the  eye  of  the  observer  without  st()0]>ini;,  and  until  the  table 
top  is  thus  an  easy  steady  rest  for  the  forearms  during  manii)ulations 
of  the  cystoscope.  The  lower  extremities  are  then  placed  in  the  lith- 
otomy, exas^t^erated  lithotomy  or  droojiiuii;  ])osition.  entirely  in  accord- 
ance with  the  ])atient's  comfort.  The  head  i)iece  of  the  table  is  raised 
so  that  the  tnnik  and  head  are  flexed  on  the  pelvis  until  the  head  is 
hifjh  enouc;h  to  jjrevent  rush  of  blood  into  it.  The  upper  extremities 
of  the  ]iatient  are  laid  across  the  chest  under  the  sterile  towels.  This 
might  be  called  the  posture  of  moderate  universal  flexion  which  is 
known  to  be  that  of  great  comfort,  case  and  satisfaction. 


Fig.  194. — Author's  cystoscopic  table  adjusted  for  the  posture  of  "universal  flexion. 


The  fidl  sitting  posture  or  nearly  sitting  posture  is  also  a  very  con- 
venient one  with  a  few  restrictions.  Serious  difficulty  arises  if  the 
patient  starts  to  faint  which  is  by  no  means  an  imcommon  experi- 
ence. Apprehensive  patients  may  readily  watch  all  that  is  going  on 
and  greatly  augment  their  already  undue  fears  by  not  understanding 
the  simplicity  of  the  various  procedures. 

Instnunent  Table. — This  important  furnishing  should  be  sufficiently 
large  to  contain  the  essentials  at  the  immediate  right  and  direct  reach 
of  the  operator,  and  the  accessories  of  the  cystoscopy  at  the  opposite 
or  nurse's  end  of  the  table. 

The  essentials  alluded  to  comprise  the  means  of  irrigation,  illumi- 


PREPARATION  FOR  CYSTOSCOPY  725 

nation,  examination,  ureteral  catheterisrn,  vesical  treatment  both 
instrumental  and  electrical.  The  latt(;r  therefore  includes  the  gener- 
ation, regulation  and  application  of  tlic  Onrliii  and  d'Arsonval  currents 
when  necessary. 

The  accessories  under  the  charge  of  the  nurse  include  the  details  of 
the  dressings,  the  towels  and  the  linen.  To  these  may  sometimes  be 
added  the  full  irrigation  equipment  which  the  rmrse  often  operates 
under  order  from  the  cystoscopist. 

The  assistant  stands  at  the  cystoscopist's  left  for  independent  service 
of  his  needs  and  the  patient's.  The  floor  plan  of  a  cystoscopic  room  is 
practically  that  of  any  other  operating  room. 

Nurse's  Duties  in  Cystoscopy  should  be  submitted  to  written  form 
and  should  cover  at  least  the  details  hereinafter  named :  provision  and 
preparation  of  the  operating  table;  instrument  table;  hand  basins  of 
antiseptics;  containers  of  sterile  water  and  of  2  per  cent,  boric  acid 
water;  sterilized  sheets  and  draperies;  sterilized  and  common  towels; 
sterilized  gauze  in  handkerchiefs  and  balls ;  sterilized  absorbent  cotton 
in  bulk  and  balls ;  glass  graduates  in  full  assortment ;  syringes  in  com- 
plete series  for  bladder,  urethral  and  hypodermatic  service;  local 
anesthetics  for  urethral,  vesical  and  subcutaneous  application  (alypin, 
cocain  and  eucain) ;  urethral  sounds  and  urethral  catheters  in  sterile 
towels  or  the  latter  in  tubes;  a  reasonable  line  of  instrument  trays,  test- 
tubes,  glasses  and  bottles  for  specimens;  lubricants  (preferably  boro- 
glyceride  or  a  semifluid  preparation  of  Irish  moss) ;  antiseptics  for  the 
field  (by  choice  10  per  cent,  silver  nitrate  solution  for  application  and 
for  irrigations  styptics  in  suitable  strength) ;  test  dyes,  particularly 
ampoules  of  phenosulphonephthalein  and  indigocarmine. 

The  nurse  should  also  prepare  the  field.  The  female  nurse  should 
douche  the  vagina  and  wash  the  vulva.  The  male  attendant  should 
cleanse  the  penis,  scrotum  and  surrounding  parts.  Both  should  give 
the  enema  and  see  that  the  skin  is  clean  from  the  knees  to  the  navel 
in  all  directions  unless  a  general  body  bath  has  been  possible. 

Operator  and  Assistant,  when  the  nurse  is  ready  with  the  foregoing 
duties  performed,  scrub  up  in  approved  fashion,  remove  the  mstruments 
from  the  sterilizer  or  containers,  such  as  towels,  bags  or  boxes,  lay  them 
out  on  the  table,  adjust  the  cables  and  test  the  connections,  switches 
and  lights.  In  their  direct  service  for  these  points  the  nurse  brings  in 
the  special  sterilizers  or  containers,. which  she  opens  and  presents  so 
that  everything  remains  sterile,  including  the  cystoscopes,  electrical 
equipments  and  other  accessaries  and  the  like,  and  so  that  the  operator 
and  his  assistant  are  not  at  all  contaminated  by  touching  anything  that 
is  not  sterilized.  The  layout  is  then  covered  carefully  with  sterilized 
towels,  the  patient  brought  in  and  arranged  on  the  table,  then  the  nurse 
washes  up  very  carefully,  uncovers  the  instruments,  whereat  ever^-thmg 
is  ready  for  the  cystoscopist  to  begin. 

Cystoscopy  in  the  Home  includes  supplies  for  which  the  family  are 
responsible  and  the  preparation  of  which  the  nurse  and  the  operation 
must  provide. 


726  CYSTOSCOPY 

Materials  from  the  Family  include  sterilized  dry  goods  in  full  assort- 
ment, towels,  sheets,  gauze,  cotton,  rubber  sheeting  and  table  oilcloth, 
various  utensils  such  as  slop  jar,  hand  basin,  pitchers  or  bottles  for  hot 
and  cold  sterilizeil  water,  ironing  board  or  table  leaves  for  passing  be- 
tween the  mattresses  of  the  bed  when  a  table  cannot  be  provided,  as 
much  preferred.  The  examination  may  be  done  with  equal  accuracy 
either  on  the  bed  or  on  the  table,  but  the  bed  is  so  low  as  to  constitute 
a  real  obstacle  for  facile  Avork. 

Details  in  Charge  of  the  Nurse  \"ary  in  home  work  from  those  in  ofhce 
or  hosi)ital  work  only  in  the  oversight  she  must  have  as  to  the  duties 
of  the  family,  otherwise  they  are  identical. 

Instruments  and  Supplies  of  the  Operator  and  Assistant  comprise  either 
a  uni\"ersal  or  eomiiosite  cystoscojie,  or  a  series  of  cystosco])es,  es])e- 
cially  a  small  examination,  a  direct  catheterism  and  an  indirect  catheter- 
ism  instrimient,  including  a  retrograde  vision  telescope.  For  female 
cases  a  set  of  Kelly's  direct  vision  cystoscopes  may  be  added  in  suitable 
cases.  The  full  irrigation  equipment  of  syringes  and  rubber  tubing, 
and  the  electrical  layout  of  cables,  batteries,  transformer  or  controller 
with  resistance  lamps,  together  with  sounds  for  urethral  exploration 
are  included.  Urethral  and  ureteral  catheters,  test-tubes,  glasses, 
bottles  and  graduates  for  specimens  are  important,  likewise  drugs  such 
as  cocain.  alyi)in,  nitrate  of  silver  and  the  lubricants. 

Arrangement  of  the  Room  is  exactly  the  same  as  in  the  office  or  hospital 
so  far  as  the  circumstances  of  the  family  and  the  general  surroundings 
will  permit. 

Floor  Plan  of  the  Room. — For  the  instruction  of  nurses  and  assistants 
in  a  brief  and  definite  manner  as  to  furniture,  dressings,  utensils,  instru- 
ments and  similar  supplies  necessary  for  a  cystoscopy,  it  will  be  found 
that  a  floor  plan  of  the  room,  as  a  diagram  and  inventory,  which 
contains  most  of  the  essentials  will  be  of  great  convenience. 


Fig.  195. — The  cystoscopic  field  in  the  corrected  image  instrument.    (Marion,  Heitz- 

Boyer,  Germain.) 

TECHNIC  OF  CYSTOSCOPY. 

Details  of   technic  of   cystoscopy  respect  the    following  points  in 
addition  to  such  as  have  been  elucidated  by  the  foregoing  sections — 


TECH  NIC  OF  CYSTOSCOPY 


727 


the  position  of  the  patient;  the  general  and  local  anesthesia  of  tin,' 
patient;  preparation  of  the  bladder;  the  standard  management  of 
simple  cases,  and  of  difficult  cases;  and  the  recognition  of  the  causes 
of  complications  and  failures  in  the  examination. 

Postures  of  the  Patient. — Postures  of  the  patients  vary  within  the 
choice  of  most  cystoscopists.  The  writer  has  found  that  the  average 
patient  is  most  comfortable  for  himself  and  most  manageable  for  the 
examination  when  placed  in  what  has  been  denominated  a  few  pages 
back  as  the  position  of  moderate  universal  flexion.  'J'his  term  means 
the  dorsal  decubitus  posture  with  the  trunk  slightly  flexed  upon  itself 


Fig.   196. — Universal  flexion  posture  for  cystoscopy. 


so  as  to  bring  the  head  above  the  level  of  the  elevated  pelvis,  and  with 
the  lower  extremities  either  in  the  lithotomy  position  or  in  the  drooping 
position  at  each  side  of  the  operating  table.  In  addition  to  this  attitude 
of  moderate  universal  flexion  many  cystoscopists  elect  the  lithotomy 
or  exaggerated  lithotomy  positions,  with  or  without  elevation  of  the 
pelvis,  both  of  which  are  too  well  known  to  need  further  notation. 
The  genufacial,  otherwise  called  the  genupectoral  or  knee-chest  pos- 
ture, is  limited  entirely  to  female  cases,  and  among  these  only  to  those 
available  for  the  cystoscopic  tubes.  The  difficulties  and  disadvantage 
of  this  attitude  for  both  patient  and  operator  are  obvious  and  have 
already  been  alluded  to. 


728 


CYSTOSCOPY 


The  sitting  posture  is  one  of  great  couveiiieiiee  if  the  i)atient's  self 
control  against  fainting  or  other  nervous  manifestation  is  known,  as 
it  maintains  the  floor  of  the  bladder  in  about  the  same  jiosition  as  it  has 
when  the  patient  is  amhulant.  It  recjuires  a  tahle  whieh  may  be  con- 
verted into  a  chair  with  a  generous  back  and  side  arms,  a  middle  piece 
which  is  not  longer  than  the  thighs  acting  as  the  seat  of  the  chair,  and 
foot-rests  which  permit  abduction  of  the  thighs.  The  patient  is  then 
brought  as  near  the  edge  of  this  "  chair"  as  convenient  so  as  to  i)ermit 
manii)ulation  of  the  cystoscope.  The  difficulty  of  nuuiaging  the  instru- 
ment after  its  introduction  with  the  patient  seated  is  one  of  the 
obstacles  to  the  sitting  ]-)osture  as  well  as  the  danger  of  syncope  while 


Fig.  197. — Lithotomy  posture.  The  body  is  horizontal,  the  head  elevated  on  a  pillow, 
the  perineum  is  at  the  edge  of  the  tahle,  the  knees  flexed  on  Bierhoff  rests  and  the  thighs 
well  flexed  upon  the  trunk.  The  pelvis  may  be  elevated  by  raising  the  table  top.  The 
lower  extremities  may  be  strongly  flexed  upon  themselves  and  the  trunk  constituting 
exaggerated  lithotomy  posture. 


the  attention  of  the  operator  is  directed  away  from  the  general  state 
of  the  patient. 

The  position  of  moderate  general  extension  \\hich  is  the  converse  of 
that  of  moderate  universal  flexion  is  hel])ful  in  nervous  patients  for 
simple  inspection  only.  It  is  the  dorsal  decubitus  posture  with  the 
lower  extremities  extended  and  widely  abducted.  The  operator  must 
twist  and  crane  his  neck  to  the  level  of  the  eye])iece  from  his  position 
standing  at  the  side  of  the  patient.  The  great  discomfort  of  this  atti- 
tude combined  with  the  fact  that  the  table  top  limits  the  depression 
of  the  eyepiece  within  very  narrow  extent  are  the  chief  valid  objections 
to  this  arrangement  of  the  patient. 


TEC  If  NIC  OF  CYSTOSCOPY 


729 


Changes  in  Posture  of  the  Patient  are  frc(juently  necessary  for  the 
purposes  of  improving  the  field  and  view  of  the  bladder,  of  passing  the 
ureteral  catheters  more  readily,  of  reaching  the  pelves  of  the  kidneys 
for  lavage  and  hydron(>phrotic  drainage  and  of  employing  radiogra})hy. 
Such  alterations  in  the  arrangement  of  the  patient  should  he  made  with- 
out removing  the  cystoscope  when  possible.  It  will  therefore  be  seen 
that  the  position  of  moderate  universal  flexion  is  the  best  because  it 
permits  the  operator  without  removal  of  the  cystoscope,  to  raise;  or 


Fig.  198. — Cystoscopy  in  the  female.  Dorsal  position,  extreme  elevation  of  the  peh-is, 
fixation  of  the  thighs  by  a  sheet-rope  passed  around  them  back  of  the  knees  and  below 
and  behind  the  shoulders.      (Kelly. i) 

lower  the  lower  extremities  to  any  position  within  the  range  of  the 
drooping  and  exaggerated  lithotomy  positions;  also  to  elevate  or  de- 
press the  pelvis  above  or  below  the  horizontal;  and  finally  to  change 
the  relation  of  the  trunk  to  any  position  between  Trendelenburg's 
and  the  sitting  postures  as  extremes.  Hence  in  the  opinion  of  the 
writer  this  is  j^cif  excellence  the  best  cystoscopic  position. 

Anesthetics. — Anesthetics  may  be  general  or  local.  The  term  gen- 
eral anesthetic  is  employed  to  mean  only  one  administered  by  uiliala- 


1  Operative  Gynecology,  1901,  vol.  i  (redrawn). 


730  CYSTOSCOPY 

tion.  As  a  rule  this  form  of  aiiostlu'sia  is  not  required  iu  cystoscopy 
unless  it  is  to  he  followed  hy  a  major  operation  or  unless  it  is  desired 
not  to  disturb  the  patient  through  full  knowledge  of  comlitions  diag- 
nosed antl  discussed  by  the  professional  persons  present.  Inasmuch  as 
cystoscopy  is  so  frequently  perfi)nned  on  the  subjects  of  more  or  less 
severe  and  hazardous  renal  conditions  the  best  anesthetic  is  ])robably 
nitrous  oxide  gas  and  oxygen.  Chloroform  has  the  disadvantage  of 
sometimes  causing  delayed  disturbance  of  the  kidneys  during  the  three 
or  four  days  just  after  its  administration,  and  ether  that  of  immediate 
disturbance  of  these  organs  iluring  tiie  first  twenty-four  hours.  In  any 
event  a  specialist  in  anesthesia  should  always  be  employed  when  avail- 
able, so  that  not  only  may  the  most  suitable  anesthetic  or  sequence  of 
anesthetics  be  chosen  but  the  technical  administration  may  be  the 
safest  and  wisest  possible. 

The  term  local  anesthetic  in  cystoscopy  denotes  all  those  measures 
administered  otherwise  than  by  inlialation  and  therefore  includes 
spinal,  sacral,  rectal,  hypodermic,  vesical,  urethral  and  meatal  anes- 
thesia. Spinal  and  sacral  anesthesia  are  analogous  in  that  sterilized 
1  m  500  cocain  solution  is  injected  respectively  into  the  spinal  or 
sacral  canals.  The  total  dose  must  never  exceed  one  grain  of  cocain 
and  as  much  less  as  possible.  Strange  as  it  may  seem,  a  hypodermic 
injection  of  morphin  fifteen  minutes  in  advance  is  a  serviceable  physio- 
logical antidote  to  cocam  intoxication  and  exhilaration.  The  technic 
of  spinal  anesthesia  is  well  established  while  that  of  sacral  adminis- 
tration, according  to  the  method  worked  out  by  Dr.  Jerome  T.  Lynch^ 
and  described  by  him  is  as  follows:  The  safest  method  to  adopt, 
especially  by  those  who  are  not  very  familiar  with  this  procedure,  is 
to  make  an  incision  a  little  in  front  of  the  sacrococcj-geal  joint,  and  if 
necessary  extend  it  until  an  opening  is  found.  This  can  be  done  under 
local  anesthesia. 

The  point  at  which  the  needle  is  to  be  inserted  is  first  decided  upon. 
This  can  be  determined  by  follo\N'ing  the  sacral  spinous  processes  until 
they  are  found  lacking.  Slightly  above  this  point  will  be  found  the 
opening  canal.  If,  as  happens  in  most  cases,  we  have  a  bifid  spine,  the 
ridges  can  be  easily  felt,  except  in  very  fat  subjects.  If  the  canal  opens 
near  the  sacrococcygeal  joint  this  point  is  selected.  Then,  having  first 
determined  the  point  at  which  the  needle  is  to  be  inserted,  and  this  is 
always  in  the  median  line,  it  is  painted  with  tincture  of  iodin.  Next, 
a  little  ethyl  chlorid  is  sprayed  on  the  skin  and  a  hypodermic  syringe, 
containing  a  solution  of  1  to  500  cocain,  with  an  ordinary  hypodermic 
needle,  is  next  employed  in  order  to  anesthetize  the  skin  over  the 
area  in  which  the  needle  is  to  be  inserted,  so  that  a  small  incision  can 
be  made  without  causing  any  pain.  It  is  always  better  to  incise  the 
skin  in  order  to  obviate  any  chance  of  infection. 

The  following  procedure  is  used  in  passing  the  needle:  The  needle 
is  grasped  in  the  right  hand,  and  the  index  finger  placed  close  to  the 

1  Med.  Rec,  February  8,  1913. 


TECH  NIC  OF  CYSTOSCOPY  731 

point.  It  is  then  passed  at  an  angle  of  al)out  15  degrees  until  the 
bone  is  reached.  The  needle  is  then  passed  close  to  the  bone  until  it 
has  been  entirely  inserted  for  about  one  inch.  At  this  juncture  it  is 
well  to  pause  and  determine  whether  the  needle  is  in  tlie  canal  or  not. 
This  can  be  determined,  as  stated  before,  by  moving  the  needle  back 
and  forth,  up  and  down,  and  from  side  to  side.  If  it  is  in  the  canal 
the  wall  will  be  found  on  all  sides,  and  if  not  the  needle  will  pass  readily 
through  the  skin. 

When  the  needle  is  found  to  be  in  the  canal,  about  4  c.c.  of  the  same 
solution  is  deposited  on  each  side.    This  is  usually  sufficient. 

Rectal  anesthesia  in  cystoscopy  is  usually  secured  through  sup- 
positories, chiefly  of  opium  and  belladonna,  or  through  small  enemata 
of  the  bromids  and  chloral.  Enemata,  however,  are  not  advised  as  the 
rectum  should  be  empty  and  at  rest  for  some  period  prior  to  entrance 
into  the  bladder.  On  the  same  ground  but  in  less  degree  suppositories 
are  faulty  unless  opportunity  for  melting  has  been  given. 

Vesical,  urethral  and  meatal  anesthesia  in  cystoscopy  is  maintained 
by  the  writer  with  the  following  technic:  After  suitable  cleansing  of 
the  bladder  and  urethra  with  a  catheter,  the  bladder  is  moderately  dis- 
tended with  alypin  solution  (2  to  4  per  cent,  in  water).  About  one  inch 
back  from  the  meatiis  a  rubber  elastic  band  is  slipped  tightly  over  the 
penis  for  a  watertight  hold  on  the  catheter.  While  the  catheter  is 
slowly  withdrawn  the  alypin  solution  is  flooded  into  the  urethra  until 
moderate  distention  is  secured.  After  this  the  catheter  is  withdrawn 
while  the  band  closes  the  urethra  and  imprisons  the  anesthetic  behind 
it.  The  meatus  is  now  anesthetized  by  dropping  a  few  minims  of  10 
per  cent,  cocain  solution  in  water  into  it  while  it  is  held  open.  This 
procedure  will  ordinarily  anesthetize  the  whole  urethra  and  the  bladder 
in  about  five  minutes  with  very  little  change  in  the  appearance  of  the 
mucosa. 

Eucain  in  similar  or  slightly  weaker  solutions  may  be  employed  in 
the  same  way  but  is  seemingly  more  toxic  than  alypin  although  less  so 
than  cocain.    Cocain  in  such  a  quantity  is  positively  dangerous. 

Alypin  in  2  or  4  per  cent,  suspension  in  Irish  moss  or  tragacanth 
jelly  may  be  deposited  in  the  urethra  from  end  to  end  with  the  ointment 
applicating  sound  of  the  writer.  This  has  the  advantage  of  lubricating 
the  urethra  for  the  passage  of  the  cystoscope  but  the  disadvantage  of 
pushing  before  it  into  the  bladder  the  jelly  which  lies  upon  its  floor 
until  dissolved,  which  is  often  inconvenient,  especially  as  it  may  obscure 
small  lesions  considerably. 

Depositor  sounds  or  catheters  may  be  used  for  laying  pellets  of  ah^in 
or  eucain  within  the  deep  urethra,  which  is  best  accomplished  when  the 
shaft  of  the  instrument  is  at  90  degrees  to  the  vertical  axis  of  the  body. 
The  Bradford  Lewis  urethral  applicator  is  a  serviceable  form.  It  is 
shaped  like  the  standard  silver  catheter  with  the  end  open  and  ^^th  a 
lateral  outlet  in  the  same  plane  as  the  tip  but  directed  away  from  it. 
Through  this  instrument  the  bladder  is  filled.  It  is  then  withdrawn 
until  the  outflow  just  stops,  showing  that  its  beak  is  distal  to  the 


732  CYSTOSCOPY 

sphincter.  At  this  jioint  the  pellets  are  a])plie(l  by  being  pushed  out  of 
the  vesical  oi)ening  of  the  instrument  by  a  more  or  less  Hat  faced 
obturator.  The  number  of  pellets,  of  course,  determines  the  dose.  The 
meatus  nuiy  be  anesthetized  as  just  tlescribed  with  a  few  minims  of 
cocain  water  or  with  more  alyjjin  i)ellets.  The  fault  of  this  method  is 
that  the  urethra  between  the  meatus  is  usually  not  at  all  atl'ected  by 
the  anesthetic,  which  shoukl  not  be  the  case  if  it  is  worth  while  ushig 
any  anesthesia. 

Female  cases  demand  a  slightly  different  management  with  regard 
to  the  invthra  alone  which  corres])()nds  with  the  ])rostatic  urethra  in 
the  male,  but  is  flaccid,  wide  and  dilatable.  I'sually  a  few  ])ellets  of 
alypin  may  be  deposited  into  the  meatus  which  is  commonly  the  point 
of  most  sensitiveness. 

(^hoice  of  local  anesthetic  is  reached  solely  through  consideration  of 
the  general  nature  of  the  case.  Asa  rule,  examinations  of  simi)le  char- 
acter recpiire  only  gentleness,  deliberation  and  dexterity  in  order  to 
reach  a  final  opinion;  in  this  manner  no  anesthetic  is  usually  employed 
ill  them.  On  the  other  hand,  nervous  patients  may  require  the  adminis- 
tration of  sedatives  locally  as  well  as  generally.  The  bladder  itself 
may  demand  local  anesthetics  from  the  nature  of  its  suspected  lesion, 
such  as  inflammation,  foreign  body  and  tmnor.  Incontinence  of  vesical 
or  spinal  origin  is  another  important  requirement,  while  pus  and  blood 
from  the  bladder  wall  make  U])  the  list.  If  in  these  various  conditions 
the  blad<ler  is  not  (juiet  and  insensitive  the  examination ^^■illbedefeatcd, 
either  through  agitation  of  the  patient  or  spasmodic  action  of  the 
bladder  wall.  The  former  will  prevent  the  operator  from  securing  the 
cooperation  of  the  patient  while  the  latter  will  cause  the  recurrence  of 
hemorrhage,  purulent  discharge,  incontinence  and  the  like.  As  a  rule, 
the  gentle  instillation  of  a  solution  such  as  2  or  4  per  cent,  alypin  in 
warm  water  into  the  bladder,  step  by  step,  up  to  full  distention  is 
sufficient.  When,  however,  conditions  are  such  that  the  bladder  will 
not  retain  even  this,  then  sjiinal  or  sacral  anesthesia  is  necessary.  Other 
points  in  the  decision  are  the  importance  and  difficulty  of  the  case.  If 
the  lesion  is  one  of  gravity  with  the  diagnosis  resting  on  a  close  decision, 
then  by  no  means  should  the  best  obtainable  form  of  anesthesia  be 
omitted.  For  this  reason  spinal  and  sacral  anesthesia  fulfil  the  widest 
range  of  indications.  One  can  hardly  go  wrong  in  giving  them  first 
place  in  such  circumstances. 

Prerequisites. — Prerequisites  of  successful  cystoscopy  may  be 
summed  up  as  follows: 

1.  Mentally  assured,  nervously  quiet  patient,  with  a  urethra  of 
known  patency,  preferably  24  F.  to  26  F.,  otherwise  adapted  to  any 
of  the  special  subcaliber  cystoscopes,  bS  F.,  15  F.,  or  13  F. 

2.  Asepsis  and  antisepsis  of  instruments,  accessories  and  dressings, 
patient,  operator  and  assistants. 

3.  Mediiun  of  vesical  distention,  transparent,  translucent,  clean, 
clear  and  unirritating. 


TEC II NIC  OF  CYSTOSCOPY  733 

4.  Good  steady  illumination,  not  so  intense  as  to  tire  the  eye  of  the 
opt^rator,  or  so  potent  as  to  burn  out  the  lamp. 

5.  Bladder  dilatable  to  100  to  150  cm.  without  pain,  spasm  or 
incontinence. 

6.  Bladder  as  free  as  reasonable  from  points  discharging  blood  or 
pus.  Frequently  such  a  bladder  is  obtainable  only  after  the  due 
administration  of  local  or  general  anesthetics  and  gentle  but  free 
irrigation  with  styptics  and  pus-solvents. 

Essential  Preliminaries.— Essential  preliminaries  to  cystoscopy  may 
be  enumerated  in  the  following  manner,  including  first  those  inde- 
pendent of  the  patient  himself  and  second  those  dependent  on  the 
patient  himself. 

In  the  former  class  belongs  the  electrical  equipment  in  particular, 
which  should  always  be  investigated  at  short  regular  intervals  for  the 
major  parts  of  the  apparatus  and  before  each  cystoscopy  for  the  minor 
parts  of  it. 

Asepsis,  antisepsis,  patience  and  perseverance  are  the  watchword 
of  success. 

1 .  Batteries  should  be  examined  at  least  once  a  week  for  dead  dry 
cells  or  polarized  elements  of  the  moist  cells.  The  ordinary  pocket 
voltmeter  is  serviceable  and  sufficient  as  a  rule. 

2.  Wires  and  cables  must  be  examined  for  loose  or  dirty  connection 
and  for  broken  or  moist  insulation. 

3.  Switches  should  make  firm,  clean  contact  between  brightened 
metal  contact  parts. 

4.  Cystoscopes  must  be  inspected;  their  essential  elements  counted, 
fitted  and  arranged;  their  lens  systems  tested,  prefei*ably  in  water  on 
a  familiar  object;  their  illumination  regulated  to  the  proper  degree  of 
intensity  to  give  a  good  view  of  the  object  under  water  with  continuous 
light  and  next  with  the  light  turned  on  and  off  several  times;  their 
irrigation  circuits  must  be  free  of  obstruction  and  of  leaking  faucets 
and  connections;  their  ureteral  catheters  must  be  tested  for  patency, 
assembled  on  the  catheterizing  telescope  with  their  distal  tips  just  back 
of  the  deflector  and  their  proximal  ends  plugged  with  pins  against 
leakage. 

The  essential  elements  of  the  cystoscope  include  the  sheath  with 
its  electrical  outfit  complete,  the  obturator  and  the  telescopes  for 
inspection,  ureteral  catheterization  and  retrograde  examination,  if  the 
instrument  is  designed  to  do  these  threefold  functions.  Otherwise 
separate  cystoscopes  must  be  at  hand  accordmgly. 

Spots  on  the  lens  system  are  due  to  foreign  matter  on  the  eye-piece 
or  objective  lens,  which  should  be  accordmgly  cleansed.  If  general 
blurring  is  present  water  is  usually  in  the  telescope  among  the  various 
lenses. 

Irrigation  may  fail  through  dried  pus  or  blood  in  the  stop-cocks, 
which  may  be  removed  with  wires  fitting  the  lumen  properly. 

Illumination  may  be  uncertain  or  fail  through  a  number  of  causes 
which  must  be  determined  bv  regular  search  from  the  source  of  the 


734  CYSTOSCOPY 

electricity  to  the  lamp,  as  set  forth  in  the  prece(Hn<::  ] paragraphs; 
namely,  the  operator  must  prove  no  defect  to  exist  hi  the  batteries,  the 
wires,  the  cables  and  the  switches,  especially  the  switch  in  the  coupler 
at  the  cystoscope.  After  this  is  done  the  trouble  may  be  traced  by  the 
following;  steps: 

1.  Change  of  cytoscope  may  at  once  (ix  tlie  difHculty  in  tlu>  instru- 
ment discarded. 

2.  Change  of  cable  may  similarly  locate  the  tn)ubU>  in  the  cable 
removed  not  a])])arent  to  the  i)revious  examination. 

3.  Change  of  lamp  may  serve  in  exactly  the  same  manner.  Before 
the  second  lam])  is  inserted  the  contact  within  the  socket  had  best  be 
scraped  bright  with  a  knife  and  the  little  contact  wire  at  the  base  of 
the  lamj)  lifted  slightly  outward  with  the  knife  blade  in  order  to  insure 
good  contact. 

4.  The  lamp  removed  should  be  tested  by  freeing  its  contact  wire 
as  just  described,  setting  this  carefully  against  one  pole  of  the  electric 
controller  and  with  any  convenient  instrument  completing  the  circuit 
by  comiecting  the  other  pole  with  the  outside  of  the  lamj).  If  illumi- 
nation now  fails  the  trouble  is  in  this  lamp. 

5.  The  binding  posts  of  the  cystoscope  receiving  either  the  socket 
(American)  or  spring  (European)  coupler  may  be  short  circuited  by 
moisture  admitted  during  irrigation.  In  the  modern  instruments  this 
is  impossible  Init  should  it  occur  the  coupler  should  l)e  disconnected, 
thoroughly  dried  and  replaced.  In  the  older  American  couplers  a  very 
small  piece  of  vaseline  between  the  posts  and  the  socket  will  prevent 
this  accident. 

The  essential  preliminaries  to  each  cystosc()i)y  dependent  on  the 
patient  himself  should  receive  attention  when  the  operator  is  assured 
that  all  those  independent  of  the  patient  are  in  order  as  set  forth  in  the 
foregoing  paragraphs.    Of  chief  importance  are  the  following: 

1.  Assurance  of  the  patient  which  rests  primarily  with  the  family 
physician  before  the  actual  visit  to  the  cystoscopist,  and  secondarily 
with  the  latter  in  virtue  of  a  quiet,  dignified,  orderly  manner. 

2.  Comfort  of  the  patient  which  is  reached  primarily  by  the  nurse 
in  the  adjustment  of  pillows  and  draperies,  and  secondarily  by  the 
operator  in  the  arrangement  of  the  table  so  that  the  patient's  muscular 
system  will  be  relaxed  and  nervous  system  imdisturbed. 

3.  Preparation  of  the  bladder  is  one  of  the  most  hnportant  details 
of  success  and  may  be  considered  under  the  following  headings: 

Preparation  of  the  Bladder  in  Uncomplicated  Cases. — Some  authori- 
ties teach  that  when  the  urine  is  clear  and  the  bladder  not  greatly  dis- 
eased the  urine  may  be  retained  as  the  distending  medium.  For  the 
experienced  expert  this  may  be  an  allowable  rule;  but  on  the  whole  it 
is  best  to  become  accustomed  only  or  chiefly  to  the  appearance  of  the 
mucous  membrane  through  one  standard  medium  of  distention,  namely, 
clear  normal  salt  solution  or  2  per  cent,  boric  acid  water,  both  sterilized, 
of  course.  The  wisdom  of  this  rule  is  axiomatic  just  as  is  the  common 
sense  of  the  rule  that  one  should  become  so  far  as  possible  skilful  in 
the  use  of  one  kind  of  cystoscope  before  taking  up  others.    The  color 


TEC II NIC  OF  CYSTOSCOPY  735 

of  the  urine  varies  so  that  the  deeper  shades  are  capable  of  chanj^in^  the 
color  of  the  mucosa  greatly,  hence  the  appropriateness  of  a  colorless 
medium  whenever  possible. 

There  is  one  exception  to  this  objection  to  the  urine  as  a  medium  of 
distention — namely,  tuberculosis  of  the  bladder,  which  is  usually  so 
intolerant  to  any  other  medium  than  the  urine  that  the  latter  must  be 
employed,  provided,  of  course,  there  is  no  pus  or  })lood  present. 

Distention  of  the  bladder  must  respect  the  comfort  of  the  patient, 
rest  to  the  bladder  and  the  unfolding  of  the  mucous  membrane  as  a 
whole,  so  far  as  practical.  Hence  the  amount  of  fluid  or  air  injected 
must  not  cause  pain  by  pressure  or  irritation  either  by  the  chemical 
character  of  the  fluid,  or  by  mechanical  excitation  of  the  evacuation 
reflex.  In  the  average  male  bladder  from  100  to  200  c.c.  of  fluid  and 
in  the  female  about  100  c.c.  additional  will  secure  these  desiderata. 
Increase  in  the  distention  is  always  a  reserve  in  the  hands  of  the  cysto- 
scopist  for  diagnosticating  under  the  eye  the  meaning  and  limits  of 
trabeculations,  diverticula,  deformities  and  fixations  due  to  extra- 
vesical  and  intravesical  tumors. 

The  amount  of  fluid  injected  should  always  be  measured  in  both 
complicated  and  uncomplicated  cystoscopy  as  a  guide  to  diagnosis; 
for  example,  in  some  neuroses  of  the  bladder  without  obvious  disease  of 
its  walls  relatively  little  capacity  exists,  which  may  not  be  apparent 
unless  the  quantity  of  fluid  injected  is  measured  at  the  time  of  the 
cystoscopy  and  subsequently  tested  for  comparison  and  variation. 

The  limit  of  distention  is  the  greatest  among  which  the  patient  will 
tolerate  without  pain,  spasm  or  nervous  irritation,  and  which  will  pro- 
duce a  size  of  bladder  within  the  limits  of  the  mechanical  and  optical 
reach  of  the  cystoscopy  In  other  words,  the  bladder  may  best  be 
studied  in  a  condition  of  great  enlargement  provided  the  cystoscope 
may  be  carried  to  the  proper  focal  distance  in  all  directions.  If  this 
degree  of  distention  is  exceeded,  manifestly  the  work  of  cystoscopy  will 
fail  of  definite  results. 

Choice  of  medium  of  distention  is  between  air  and  fluid.  Air  is  avail- 
able and  advantageous  when  the  walls  of  the  bladder  are  discharging 
blood  or  pus  so  rapidly  that  a  fluid  medium  cannot  be  kept  translucent 
and  transparent  for  the  examination.  In  these  circumstances  air 
affords  a  good  opportunity  to  view  the  bladder  as  a  whole  and  perhaps 
to  locate  the  chief  points  of  discharge.  But  the  accumulation  of  the 
blood  or  pus  on  the  mucosa  soon  obscures  a  study  of  it  so  that  the 
operator  is  soon  no  better  off  than  he  was  with  the  increasing  turbidity 
of  the  fluid.  The  difficulty  may  ordinarily  be  circumvented.  Having 
located  the  chief  bleeding  point  or  points,  the  cystoscopist  evacuates 
the  air  and  replaces  it  with  sterilized  normal  salt  solution,  using  the 
catheterizing  cystoscope  mounted  -^ith  a  5  F.  and  a  7  F.  ureteral 
catheter;  the  larger  as  inlet  and  so  adjusted  as  to  clear  the  field  of 
pus  or  blood  but  not  as  to  obscure  direct  vision,  and  the  smaller  as 
outlet  permit  him  to  examine  each  lesion  in  the  presence  of  flowing 
solution,  with  the  one  setback  of  a  swirl,  but  with  the  great  gam  of  a 
clear  field. 


736  CYSTOSCOPY 

Fluid  is  available  and  advantageous  in  that  it  is  physiological  in  the 
bladder,  may  be  used  as  a  direct  index  of  capacity,  floats  and  dissolves 
oti"  reasonable  cpiantities  of  blood  and  ])us  from  the  mucosa,  sui)])orts 
fragments  of  delicate  tumors  such  as  ])a])illoniata,  and  by  the  in  and 
outflow  method  displaces  offending  foreign  substances  from  the  field. 
Fluid  is  moreover  the  medium  in  which  the  optical  systems  of  modern 
cystoscopes  give  the  best  i)ictures  with  the  fewest  aberrations.  Fluid 
is  likewise  the  only  medium  in  which  modern  treatment  of  the  bladder 
wall  exemplified  by  the  Oudin  high-fi-e(|ueiic>'  current  may  be  carried 
out  to  the  best  adx'antage. 

Management  of  the  Bladder  in  Complicated  and  Difficult  Cases. — 
The  urinary  bladder  may  i)resent  comi)licated  difhculties  to  examina- 
tion from  its  walls  as  wholes,  its  mucous  membrane  lining  proper,  its 
contents,  its  dilatability  and  its  annexa. 

1.  The  bladder  walls  as  wholes  may  obstruct  cystoscopy  through 
paralysis  and  dilatation  or  hypertrophy  and  contracture  of  the  muscul- 
aris.  The  former  state  frequently  increases  the  capacity  of  the  bladder 
beyond  the  meciianical  length  and  focal  distance  of  the  cystoscope  in 
all  directions  except  just  around  the  neck  and  base.  The  latter  state 
may  so  limit  the  amount  of  distention  that  no  picture  of  the  blaflder 
capacity  as  a  whole  is  obtainable  but  only  partial  views  with  one  of  the 
newer  close  vision,  restricted  field  instruments,  such  as  the  Braasch 
and  the  Acmi  convex  sheath  types. 

Contracted  bladders  may  be  defined  as  those  whose  capacity  has 
been  reduced  to  a  third  part  of  the  normal,  namely,  from  150  to  50  c.c. 
or  less.  Such  ])ladders  do  not  ])ermit  satisfactory  examination.  Rarely 
repeated,  protracted,  slow  dilatation  may  enlarge  the  bladder  a  little, 
to  which  may  be  added  the  proper  selection  of  anesthetics.  At  best, 
however,  contracted  bladders  are  extremely  unsatisfactory  to  deal  with. 

2.  The  mucous  lining  proper  of  the  ])ladder  may  limit  cystoscopy 
through  acute  intrinsic  and  extrinsic  inflammations,  hemorrhage  and 
pus.  In  the  inflammations  the  normal  gloss  of  the  epithelium  and 
the  outlines  of  the  bloodvessels  are  so  lost  that  only  recognition  of  the 
process  as  acute  is  possible;  moreover  the  sensitiveness  and  intolerance 
of  the  bladder  in  these  circumstances  contraindicate  instrumental 
entrance. 

Hemorrhage  may  be  focal  or  somewhat  general  from  the  mucosa  and 
may  require  patient  irrigation  of  the  bladder  with  hot  styptic  solutions, 
the  use  of  sacral  or  spinal  anesthesia,  air  as  a  means  of  distention  or 
the  double-current  irrigation  througli  ureteral  catheters,  previously 
spoken  of.  Hemorrhage  may  proceed  from  the  kidneys  and  ureters,  in 
which  case  irrigation  usually  clears  the  cavity  thoroughly  for  diagnosis 
unless  the  amount  of  blood  is  extreme;  even  then  tlie  bl(>eding  ureter 
may  readily  be  recognized  by  prompt  work. 

Pus  in  the  bladder  follows  the  same  general  law  as  blood  as  to  origin, 
effect  and  management.  Pus  from  the  mucosa  as  a  whole  is  one  of  the 
most  vexatious  offences  to  easy  work  because  it  deprives  the  medium 
of  transparency,  although  translucency  may  dece])tively  persist  for 
some  time  after  diagnostic  mspection  of  the  mucosa  is  impossible. 


TI'JCIINJC  OF  (JYSTOSCOI'Y  I'M 

Not  infrequently  thcrapcusis  of  the  bla(l(l(;r  tlirongli  li(;aliii^  irri- 
gations and  the  judicious  administration  of  urinary  antiseptics  and 
sedatives  will  cause  such  a  decrease  in  th(;  amount  of  pus  as  to  render 
cystoscopy  adequate.  This  is  particularly  true  in  infections  of  the 
bladder  with  the  colon  bacillus  which  almost  invariably  yields  rapidly 
to  the  various  antiseptics  which  liberate  formaldehyde  in  the  urine. 

Incontinence  of  the  bladder  that  does  not  depejid  on  acute  infhini- 
mation  and  similar  severe  conditions  may  frequently  be  controlled  by 
appropriate  posture  of  the  patient.  If  the  pelvis  is  elevated  almost  to 
the  Trendelenburg  degree  so  that  the  weight  of  the  distending  fin  id 
largely  gravitates  away  from  the  neck  of  the  bladder,  the  incontinence 
will  cease  at  least  long  enough  for  a  rapidly  conducted  cystoscopy. 
The  choice  of  subcaliber  cystoscopes  for  these  cases  is  also  of  service, 
as  irritation  of  the  neck  is  materially  decreased,  by  employing,  for 
example,  one  18  F.  instead  of  24  F.  instrument.  In  the  male  an  elastic 
band  may  be  tied  tightly  around  the  penis  after  the  cystoscope  is  in 
place,  which  will  often  hold  back  leakage  unless  the  spasm  of  the 
bladder  is  intense.  Subdilatation  is  also  to  be  borne  in  mind  except- 
ing that  degree  which  permits  the  bladder  to  fall  into  many  and  deep 
folds. 

3.  The  bladder  as  a  reservoir  proceeding  from  the  mucosal,  the  mus- 
cular or  the  nervous  elements  may  hinder  cystoscopy.  G  eneral  or  spinal 
anesthetics  or  the  careful  application  first  of  urethral  and  then  of  vesical 
loca'l  anesthetics  and  the  gentle  use  commonly  of  the  subcaliber  instru- 
ments, when  possible,  constitute  its  correction.  Investigation  as  to 
underlying  organic  cerebrospinal  disease  in  these  cases  must  never  be 
omitted. 

4.  The  cavity  of  the  bladder  may  prevent  cystoscopy  through  the 
presence  of  calculus,  neoplasm  and  anatomical  abnormality.  Large 
calculi  are  only  embraced  in  this  category  so  that  their  surface  makes  it 
impossible  to  obtain  the  correct  focal  distance  for  the  bladder  so  irri- 
table as  to  be  practically  undilatable.  Neoplasms  are  a  factor  through 
their  production  of  intolerance,  contracture,  hemorrhage,  pus,  necrosis 
and  detritus.   Like  calculi,  neoplasms  may  prevent  due  focal  distance. 

Anatomical  abnormality  of  the  bladder  such  as  diverticula  usually 
affects  the  cavity  of  the  abnormality  itself,  inasmuch  as  the  illumination 
and  focal  field  of  the  instrument  cannot  be  carried  into  them,  otherwise 
they  have  little  influence  on  the  examination  of  th-e  bladder  proper 
itself. 

5.  The  dilatability  or  distensibility  of  the  bladder  has  been  indirectly 
discussed  in  sufficient  degree  in  the  foregoing  paragraphs. 

6.  The  annexa  of  the  bladder,  especially  the  prostate  and  vesiculse 
seminales  in  the  male,  the  uterus,  tubes,  ovaries  and  vagina  m  the 
female,  and  the  rectum  and  cellular  planes  in  both  sexes,  may  through 
diffuse  or  focal  inflammation,  suppuration,  enlargement,  displacement, 
neoplasm  and  the  like  imitate  many  of  the  foregoing  conditions,,  and 
partially  or  totally  prevent  a  satisfactory  cystoscopy. 

Causes  of  Loss  or  Imperfection  of  Vision  in  Cystoscopy  rest  on  the 
cystoscope,  the  operator,  the  bladder  contents  and  its  annexa. 
47 


I'lG.     -JOI 


Fig.  20ii 


Fig.  203 


Fig.  204 


Figs.   199-204. — Commoli  obstructions  to  cystoscopy  and  their  correction.' 

Fig.  199. —  Shows  the  field  of  the  cystoscope  obstructed  by  the  wall  of  the  bladder, 
either  by  insufficient  dilatation  or  by  a  diverticulum.  Relief  of  the  condition  is  shown: 
(1)  by  the  cystoscopes  in  dotted  lines,  one  after  withdrawing  the  instrument  until  the 
pouch  is  cleared  and  the  other  after  elevating  the  eye-piece  in  order  to  focus  the  lens, 
and  (2)  by  increasing  the  dilatation  indicated  by  the  dotted  bladder  wall. 

Fig.  202. — Shows  the  field  of  the  cystoscope  obstructed  by  the  wall  of  the  urethra  by 
insufficient  penetration.  Relief  of  the  conditions  is  shown  by  the  cystoscope  in  dotted 
lines  suggesting  further  penetration. 

Fig.  201 — Shows  the  field  of  the  cystoscope  obstructed  by  contact  with  a  stone 
usually  by  insufficient  preparation  of  the  bladder  for  examination.  Relief  of  the  condi- 
tion is  shown:  (1)  bj-  the  cystoscopes  in  dotted  lines,  one  after  increased  advance  of  the 
instrument  and  the  other  after  depressing  the  eye-piece  to  focus  the  lens  and  the  third 
after  changing  to  a  close  vision  instrument,  and  (2)  by  increased  dilatation  indicated  by 
the  dotted  bladder  wall. 

Fig.  202. — Shows  the  cystoscope  obstructed  by  a  tumor  of  the  uterus  so  that  manipu- 
lation is  impossible.  Relief  of  the  condition  is:  (1)  by  Trendelenburg's  posture  which 
carries  the  uterus  away  from  the  liladder  as  shown  in  the  dotted  lines;  (2)  by  increased 
dilatation  as  indicated  by  the  dotted  bladder  wall;  (3)  by  advancing  the  cystoscope 
shown  by  the  dotted  instrument  and  (4)  by  changing  to  a  close  vision  instrument  also 
outlined  in  dots. 

Fig.  203. — Contains  a  tumor  of  the  bladder  covering  the  field  of  the  cystoscope.  The 
condition  is  relieved  (1)  by  increased  dilatation  as  shown  by  the  dotted  bladder  wall,  when 
possible,  and  (2)  by  changing  to  the  direct  vision  cystoscope  as  shown  in  dotted  lines. 

Fig.  204. — Contains  a  bladder  filled  with  pus  and  blood  which  caiuiot  be  thoroughly 
removed.  View  is  obtained  by  using  irripatioii  as  shown  1)\'  the  swirl  rif  fluid,  along  the 
floor  of  the  bladder. 

'  Modified  and  amplified  from  Pilchor;  Practical  Cystoscoj^y,  1911. 


TEC II NIC  OF  CYSTOSCOPY  7:V.) 

The  cystoscope  may  fail  through  defects  in  the  lamp  or  lenses.  One. 
should  always  test  the  lamp  outside  the  bladder  in  the  same  medium  as 
will  be  used  in  distention  after  bringing  the  light  up  to  white  brilliance. 
A  supply  of  reserve  lamps  shoidd  always  be  part  of  the  equipnient. 
Or  the  lamp  may  have  become  smeared  with  blood,  pus  or  lubricant 
and  thus  its  illumination  depreciated.  The  lenses  may  be  soilerl  with 
the  same  substances,  partially  or  totally  obscuring  their  field.  A  black 
spot  in  .the  field  is  recognized  as  being  in  the  lens  system  by  moving 
uniformly  with  the  instrument  in  all  directions.  Hence  the  lenses 
should  always  be  inspected  and  cleansed  before  the  telescope  is  intro- 
duced. The  lens  system  as  a  whole  may  be  out  of  commission  through 
the  entrance  of  water  into  the  telescope  at  some  point. 

The  cystoscopist  may  fail  through  unfamiliarity  with  the  science  of 
cystoscopy,  lack  of  knowledge  of  the  focal  distance  of  his  instrument  or 
of  the  correct  direction  of  his  objective.  If  the  instrument  is  a  new  one 
and  the  picture  dim  it  may  be  improved  by  making  the  objective  either 
approach  or  recede  from  the  surface  of  the  bladder.  A  blood-red  picture 
usually  means  that  the  objective  is  too  close  to  the  surface  and  should 
be  elevated  from  it  by  depressing  the  eye-piece.  Darkness  in  the  instru- 
ment or  absence  of  picture  when  the  lamp  and  electric  circuit  are  known 
to  be  perfect  means  that  the  objective  is  covered  either  in  the  neck  of 
the  bladder  or  by  the  wall  during  insufficient  dilatation,  or  by  the 
surface  of  vesical  contents  such  as  tumors,  calculi  and  the  deformation 
of  extraneous  organs  or  conditions. 

The  bladder  contents  and  annexa  cause  loss  of  picture  in  the 
manner  just  described. 

The  diagrapis  Figs.  199-204  are  designed  to  indicate  these  difficulties 
in  general.  The  dotted  outlines  of  the  instruments  show  in  general  term  s 
manipulations  which  may  correct  the  troubles  in  part  or  in  whole.  It 
should  be  remembered  that  when  such  difficulties  arise  the  ingenuity, 
patience  and  perseverance  of  the  operator  are  called  strongly  into  play. 

Resume  of  Cystoscopic  Difficulties. — Failure  in  cystoscopy  proceeds 
from  the  following  four  causes:  light,  lens,  bladder  and  contents,  and 
it  is  well  to  mention  the  chief  elements  under  each. 

The  light  may  have  loose  or  broken  connections,  burned-out  lamp  or 
short  circuit. 

The  lens  may  be  buried  in  a  flaccid  bladder,  a  diverticulimi,  or  the 
urethra.  It  may  be  covered  with  blood,  pus  or  lubricant,  especially  if 
vaseline  or  a  grease  has  been  used.  The  wrong  focal  distance  may  be 
employed. 

The  bladder  may  be  collapsed  from  escape  of  irrigation  fluid,  saccu- 
lated or  diverticulated.  Acute  inflammation  may  mask  landmarks 
and  details. 

The  contents  may  be  blood,  pus,  chyle  and  the  like,  or  a  stone  or 
tumor  may  impede  adjustment  of  the  cystoscope. 

These  difficulties  are  diagrammed  in  Figs.  199-204  in  the  black 
lines  of  the  drawing  and  the  correction  of  each  difficulty  is  shown  by  the 
dotted  lines  of  the  drawing  and  by  the  explanation  in  the  legends. 
Only  the  main  and  common  conditions  are  covered. 


CIIAPTKli    Xl\". 

THE  BLADDER. 

I.   NORMAL  BLADDER. 

INSPECTION,  LOCALIZATION  AND  ORIENTATIOl^  OF  THE 

BLADDER. 

Anatomy. — The  bladder  will  be  remembered  as  subdivided  into  the 
apex  or  summit,  the  body,  the  base,  fundus  or  floor  and  the  neek  or 
outlet.  The  ai)ex  eorres})()nds  to  the  attaehment  of  the  uraehus  and 
is  normally  the  highest  ])oint  of  the  viscus  in  both  the  empty  and  fidl 
states  and  is  co\ered  with  peritoneum  only  in  its  posterolateral  aspects. 
Anteriorly  it  forms  the  i)osterior  boundary  of  the  upper  part  of  the 
prevesical  space.  The  body  of  the  bladder  completes  this  s])ace  down 
to  the  prostate  gland  and  triangular  ligament  in  front,  lying  therefore 
behind  the  symphysis  pubis.  Posterolaterally  the  body  of  the  bladder 
is  also  covered  with  peritoneum  and  lies  against  the  uterus  in  the  female, 
the  rectum  in  the  male  and  coils  of  small  intestine  in  both  sexes.  The 
vasa  deferentia  cross  it  in  an  arched  anterointernal  direction  along 
the  sides.  The  base,  fundus  or  floor  of  the  bladtler  is  again  uncovered 
with  peritoneum  and  is  in  relation  in  the  male  with  the  prostate, 
seminal  vesicles  and  ampulla*  of  the  vasa  deferentia.  Tti  the  female 
it  is  in  relation  with  the  cervix  uteri  and  the  upper  portion  of  the 
^•agina.  In  both  sexes  it  is  crossed  and  pierced  by  the  ureters  from 
behind  forward  and  from  without  inward.  The  neck  of  the  bladder 
is  not  funnel-shaped  in  health  but  flat  where  the  sphincter  closes  it  so 
that  the  surface  is  quite  flat  excepting  the  dimple  of  the  urethral 
entrance. 

Introduction  of  the  Cystoscope. — The  preliminaries  are  the  utmost 
a.sepsis  oi  field,  instruments,  accessories  and  operators,  lubrication 
and  patency  of  the  canal.  The  technic  varies  slightly  between  the 
straight  tubes  and  the  beaked  instruments.  It  also  is  modified  by  the 
various  positions  of  the  patient,  namely,  those  of  moderate  universal 
flexion,  lithotomy,  exaggerated  lithotomy,  sitting,  genufacial  and 
moderate  general  extension.  Sex  and  age  have  an  influence  on  technic, 
children  usually  requiring  a  general  anesthetic  and  females  ordinarily 
affording  far  more  ready  insertion  of  the  instrument. 

The  instrument  is  best  passed  after  the  patient  is  comfortably  in 
the  selected  posture,  fully  draped  and  ready  for  the  examination. 

iNIoderate  universal  flexion  and  all  other  postures  except  the  genu- 
facial and  the  moderate  general  extension  rcniuire  the  o])erator  to  stand 
opposite  the  perineimi  in  the  midplane  of  the  body  in  both  males  and 
females. 


INSPECTION,    LOCALIZATION,    ORIENTATION   OF   BLADDER     741 

Beaked  instnunents  arc;  v.w^ngcd  by  their  tip  in  tlie  meatus  while 
the  shaft  is  held  in  the  niidplaiie  of  the  body  ajid  more  or  less  parallel 
with  the  abdomen.  In  males  the  penis  is  stretched  and  held  vertical 
while  the  beak  is  gently  advanced  to  the  bulb  of  the  urethra.  Here  it 
is  supported  against  the  pubic  arch,  either  by  slight  tension  upward 
or  by  gentle  pressure  with  the  free  hand  on  the  perineum,  until  the 
beak  is  felt  to  enter  the  membranous  urethra,  from  which  it  will  gently 
slide  into  the  bladder  as  the  eye-piece  is  depressed  evenly  and  gently 
until  about  parallel  with  the  operating  table.  In  healthy  urethra*  the 
foregoing  steps  are  easy.  With  the  deformity  of  prostatic  or  other  dis- 
ease, however,  considerable  patience  is  often  required  with  variations 
in  the  details.    Subcaliber  instruments  are  not  uncommonly  necessary. 


Fig.  205. — Introduction  of  the  cystoscope:  distention  of  the  bladder. 


In  females  and  in  males  with  deep  bulbous  urethrge,  the  finger  must 
support  the  urethra  respectively  in  the  vagina  and  rectmn,  as  described 
for  the  technic  of  straight  instruments. 

Straight  instruments  are  inserted  as  follows,  the  guiding  finger  being 
in  the  vagina  in  females  and  in  the  rectum  in  males.  The  penis  is  held 
straight  and  verticaland  the  tip  passed  from  meatus  to  bulb  as  before, 
with  the  shaft  in  the  midplane  of  the  body  and  vertical.  The  guidmg 
finger  is  now  inserted  and  its  tip  bent  upward  around  the  sphincter 
ani  until  it  touches  the  beak.  With  the  instrument  steadied  at  this 
level,  the  finger  is  straightened  and  pushed  forward  until  the  apex 
of  the  prostate  is  reached  and  there  brought  to  rest.  The  eye-piece 
of  the  instrument  is  now  depressed  while  the  beak  is  made  to  travel 
along  the  finger,  which  raises  it  as  it  reaches  the  apex  of  the  prostate 
so  that  it  enters  the  membranous  and  then  the  prostatic  urethrte.  The 
parallel  manipulation  in  women  is  obvious. 


742  THE  BLADDER 

In  difficult  cases  it  is  wvW  to  i)ass  a  soft  iiistniiiu'iit  first,  and  thou  to 
explore  the  relation  of  tiiis  instrument  to  the  ])rostate  thronu'li  the 
rectum  hefore  attemjiting  to  use  the  metal  instrument. 

Genufacial  posture  is  confined  to  women  and  the  Kelly  cystourethro- 
scopic  tubes.  The  introduction  is  much  the  same  as  in  the  other 
postures  in  women,  rememherinij;  only  that  in  this  attitude  the  urethra 
is  practically  horizontal,  and  that  tiierefore  the  direction  of  the  instru- 
ment is  ('hammed  almost  to  an  absolute  reverse. 

Moderate  General  Extension  requires  the  same  mani])ulation  of  the 
cystoscope  as  does  the  ilorsal  decubitus  (lisj)osition  in  ])assing  the 
ordinary  sound.  The  operator  stands  at  the  side  of  the  ])atient  and 
holds  the  instrument  either  in  the  midjjlane  of  the  body,  and  parallel 
with  the  abdomen,  or  over  the  groin,  and  parallel  with  it.  After  the 
beak  has  been  engaged  into  the  urethra  it  is  advanced  to  the  bulb  in 
the  mi(l])lane  of  the  body  from  its  first  position,  over  the  abdomen, 
or  brought  to  the  midi)lane  by  rotation  from  its  first  relation  to  the 
groin.  After  the  bulb  is  reached,  the  instrument  is  advanced  into  the 
bladder  by  elevation  against  the  symphysis  pubis  as  it  proceeds  or  by 
perineal  or  rectal  pressure. 

The  sj)hincter  of  the  ])la(lder  may  be  s])astic.  In  this  event  gentle 
pressure  and  ])atience  usually  overcome  the  difficulty.  Local  anes- 
thetics are  of  great  importance  in  preventing  it. 

Plans  of  Examination. — Regular  plans  of  examination  of  the  bladder 
vary  from  one  o])erat()r  to  another.  The  following  in  the  opinion  of 
the  author  is  the  best  method.  Inasmuch  as  the  floor  of  the  bladder 
including  the  ureters  and  the  trigonum  is  in  a  certain  sense  the  most 
important  part,  they  should  receive  first  attention  before  the  medium 
changes  or  perhaps  the  eye  of  the  operator  tires.  The  steps  of  the 
procedure  are  as  follows: 

Plan  of  Orientation  of  the  Bladder  with  the  Lateral  Vision  Cystoscope. — 
1.  The  air  bubble  at  the  apex  of  the  bladder  is  at  once  located  and 
regarded  as  in  most  cases  marking  the  highest  point  and  the  middle 
line. 

2.  The  instrument  is  then  rotated  to  the  patient's  right  through 
ISO  degrees  to  the  base  of  the  bladder  in  the  middle  line.  It  is  then 
slowly  withdrawn  until  the  posterior  of  the  red  trigonum  is  recognized, 
distinctly  set  off  from  the  paler  porti(m  of  the  base  behind  it. 

3.  The  interureteric  bar  (plica  interureterica)  is  next  distinguished. 

4.  The  instrument  is  now  rotated  to  the  ])atient's  right  along  the 
plica,  if  present,  or  if  absent  along  the  red  border  of  the  trigonum  until 
the  right  ureteric  mouth  is  reached.  The  arc  of  rotation  varies  from 
30  to  (')()  degrees  from  the  middle  point  according  to  the  proximity  of 
the  ureters  to  each  other. 

5.  The  left  ureteric  mouth  is  located  in  the  same  way  by  rotation 
in  the  opposite  direction,  30  to  60  degrees  from  the  middle  line  or 
60  to  120  degrees  from  the  right  ureter. 

6.  After  both  ureteric  mouths  have  been  studied  the  instrument  is 
withdrawn  about  3  cm.,  or  the  diameter  of  a  focal  field,  and  swept 


INSPECTION,   LOCALIZATION,   ORIENTATION   OF   BLADDER     743 


Fig.  206. — Apex  in  urachal  and  retro- 
pubic zones^  containing  air  buVjble  at 
usually  highest  and  middle  point  of  the 


Figs.  206  and  207.— Normal  bladder. 


Fig.  207. — Retropubic  zone'  with  il- 
luminated middle  portion  over  the  .sym- 
physis, less  illuminated  section  above 
this  until  the  lamp  and  lens  are  carried 
into  it  and  the  neck  encroaching  on  the 
field  below. 
(Marion,  Heitz-Boyer,  Germain.^) 


Fig.  208. — Bladder  opened,  showing  relations  of  the  ureteral  openings,  urethral 
opening  and  the  interureteric  ligament.  P.'.,  interureteric  ligament;  Fr.,  fossa  retro- 
ureterica.     (Leipmann.^) 


1  V.  C.  Pedersen:  New  York  Med.  Jour.,  August  23,  1913. 
-  Loc.  cit. 
■Leipmann's  Atlas:  Gynaekologischer  Operationskursus.  1911. 


744  THE  BLADDER 

throu^li  an  arc  of  IS^O  (lot^rci's  from  K-ft  to  rii^lit.  thus  covcriiii;'  a  field 
zone  of  tlie  trigonuni  innnc^liately  in  front  of  the  ureters. 

7.  From  this  i)osition  at  the  right  it  is  again  witlidrawn  3  em.  or 
until  the  neck  of  the  bladder  begins  to  interfere  with  the  field  and  then 
swept  ISO  degrees  to  the  left.  Usually  one  field-zone  will  cover  the 
trigonum.  but  e\ce])ti(inall>'  this  ])lan  of  Held  by  field  ])rocedure  is 
necessary. 

These  several  nianii)ulations  serve  to  stud\  the  ureters  and  trigonum 
and  the  lower  posterior  (piadrant  of  the  bladder  in  a  very  com])lete 
manner,  if  the  bladder  is  regarded  as  subdi\ided  into  anterior  and 
posterior  halves  by  the  transverse  plane  passing  through  the  neck 
and  urethral  outlet  as  the  patient  stands  in  the  anatomical  posi- 
tion. 

S.  The  instrument  is  now  advanced  to  the  interureteric  bar  again 
in  the  middle  line  as  the  chief  landmark,  and  next  o  cm.,  the  diameter 
of  a  focal  field,  beyond  it.  From  this  point  it  is  rotated  90  degrees  to 
the  patient's  right  and  next  ISO  degrees  to  the  left,  thus  covering  a 
field  zone  just  behind  the  ureters. 

9.  At  this  moment  it  is  advanced  another  3  cm.  and  rotated  ISO 
degrees  toward  the  patient's  right.  If  more  of  the  floor  remains  to  be 
inspected  the  same  manner  of  procedure  is  followed,  by  advancing  the 
instrument  into  the  bladder  about  3  cm.  and  sweeping  it  slowly  through 
ISO  degrees  from  side  to  side,  step  by  step. 

10.  When  the  upper  posterior  quadrant  has  been  in  this  manner 
completely  studied,  the  instrument  is  rotated  upward  through  ISO 
degrees  from  the  patient's  right  to  left,  thus  covering  the  most  poste- 
rior field  zone  of  the  upper  posterior  quadrant.  At  the  left  point  it  is 
withdrawn  the  diameter  of  a  cystoscopic  field  and  rotated  to  the  right 
through  ISO  degrees,  where  it  is  again  withdrawn  3  cm.,  viz.,  the  diam- 
eter of  a  field,  and  rotated  to  the  left  o\er  ISO  degrees.  These  three 
field  zones  commonly  serve  to  cover  completely  every  square  centi- 
meter of  the  upper  anterior  quadrant,  otherwise  called  the  apical,  or 
urachal  quadrant. 

11.  By  exactly  the  same  procedure  the  lower  anterior  or  retropul)ic 
quadrant  is  studied,  one  field  zone  at  a  time,  each  having  a  width  of 
one  cystoscopic  field  and  extending  from  side  to  side  through  an  arc 
of  ISO  degrees.  As  a  rule,  from  two  to  four  such  zones  complete  the 
inspection  of  this  and  all  other  quadrants. 

12.  When  the  neck  has  been  reached  as  much  as  possible  thereof 
is  inspected  in. the  same  manner  in  a  single  field  zone  in  both  the 
ureterotrigonal  and  the  retropubic  quadrants. 

It  will  be  noted  that  this  method  divides  the  bladder  into  anatomical 
divisions,  viz.,  the  fundus,  floor  or  base,  which  is  covered  by  the  uretro- 
trigonal  and  subperitoneal  quadrants  and  examined  in  accordance 
with  paragraphs  one  to  nine  as  just  stated;  and  the  apex  and  sides 
which  are  included  in  the  apical  or  urachal  and  retropubic  quadrants 
as  laid  down  in  ])aragrai)hs  ten  to  twelve  inclusive,  which  also  embrace 
the  neck  of  the  bladfler  as  perhaps  i)roperly  an  integral  zone. 


Fig.  209. — Shows  four  positions  of  the  cystoscope,  urr-s  of  rotation  und  zoiick  traversed. 


Floor 


Roof 


Fig.    210. — Presents  the  floor   of  the  Fig.    211. — Contains   the  roof   of  the 

bladder  with  its  ureterotrigonal  and  sub-  bladder  with  its  urachal  and  retropubic 

peritoneal  quadrants  and  the  four  zones  quadrant   and  the  four  zones  of  inspec- 

of  inspection  comprised  in  Fig.  209.  tion  also  indicated  in  Fig.  209. 

Fig.  209. — Four  positions  of  the  cystoscope  are  shown  in  the  order  in  which  they  are 
taken,  A,  B,  C,  D. 

The  first  position,  A,  shows  the  beak  horizontslly  placed  toward  the  patient's  right  in 
the  ureterotrigonal  quadrant  over  the  right  ureter.  From  this  point  it  is  slow-ly  rotated 
downward  through  180  degrees  in  the  direction  of  the  arrow,  A,  until  it  occupies  the 
opposite  position  horizontally  placed  over  the  left  ureter.  This  sweep  makes  it  traverse 
zone  A,  in  Fig.  210,  embracing  both  ureters  and  their  folds,  the  interureteric  fold  and  fully 
half  the  trigonum. 

The  second  position,  B,  is  made  bj'  withdrawing  the  instrument  over  the  diameter  of 
one  field  in  the  horizontal  plane  of  the  beak  at  the  last  step  of  the  first  position.  From 
this  point  it  is  rotated  downward  and  to  the  right  in  the  direction  of  the  arrow,  B,  through 
180  degrees,  until  it  occupies  the  opposite  position  horizontally  placed  over  the  right 
region  of  the  neck.  This  sweep  traverses  the  zone  B,  in  Fig.  210,  and  inspects  the  ante- 
rior portion  of  the  trigonum  and  the  neck  in  part. 

The  third  position,  C,  is  obtained  by  advancing  the  instrument  in  the  same  plane  as  it 
occupied  at  the  last  step  of  position  B,  until  it  is  beyond  the  zone  A,  and  in  the  subperi- 
toneal quadrant  represented  by  C  and  D.  It  is  now  rotated  through  180  degrees  down- 
ward in  the  direction  of  the  arrow^  C  and  thus  inspects  the  lower  half  of  the  said  quadrant, 
presented  by  C,  in  Fig.  210. 

The  fourth  position,  D,  is  reached  by  advancing  the  instrunaent  in  the  same  plane  as 
it  occupied  at  the  last  point  of  position  C  and  one  field  back  thereof.  It  is  now  rotated 
downward  through  an  arc  of  180  degrees  in  the  direction  of  the  arrow  D,  thus  completing 
inspection  of  the  upper  limits  of  the  subperitoneal  quadrant,  diagramed  in  Fig.  210,  D. 

These  four  positions,  or  if  necessary  an  increased  number  taken  in  exactly  the  same 
way,  thoroughly  examine  the  floor  of  the  bladder.  For  examining  the  roof,  the  same 
method  is  followed  but  in  the  reverse  order.  This  means  that  the  cystoscope  from  the 
last  point  of  position  D,  is  rotated  through  an  arc  of  180  degrees  upward  thus  traversing  the 
farthest  part,  D',  of  the  urachal  quadrant  D'C  in  Fig.  211.  The  remaining  zones,  C, 
and  in  the  retropubic  quadrant,  A'B',  are  inspected  in  the  order  given  by  the  same  steps. 


746  THE  BLADDER 

Plan  of  Orientation  of  the  Bladder  with  the  Axial  Vision  Cystoscope. — 
One  cannot  inchuk'  the  Kcll\-  eystonivthrosfupic  tubes  fi)r  the  reason 
that  tlie  management  of  the  lihidder  therewitli  is  so  different  from  that 
with  the  teleseo{)ie  axial  vision  instrinnents.  For  this  reason  orienta- 
tion of  the  bhidder  with  the  Kelly  tubes  is  detailed  sei)arately  as 
follows : 

1.  The  cystoscope  luning  been  introduced  with  the  ])reliniinaries 
and  cautions  previously  described  and  with  the  telescope  inserted  and 
locked,  is  held  in  the  midline  of  the  bladder  with  the  lani])  u])  and 
adjusted  to  give  a  clear  field,  which  usually  lies  in  the  ])osteri()r  superior 
or  extraperitoneal  segment  of  the  bladder. 

2.  The  cystoscope  is  withdrawn  in  the  middle  line,  maintaining  a 
clear  field  until  the  red  border  of  the  trigonmn  and  the  plica  inter- 
iireterica  is  in  view. 

3.  Maintaining  the  objective  in  the  same  plane  the  instrument  is 
made  to  travel  along  the  landmarks  m  view,  as  above,  toward  the  right 
until  the  right  ureter  and  the  ureteric  fold  lune  been  studied. 

4.  Still,  in  the  same  plane,  the  instrimient  is  swung  in  the  opposite 
direction  until  the  left  ureter  and  its  fold  haA'e  been  examined,  thus 
completing  the  posterior  zone  of  the  ureterotrigonal  segment. 

5.  With  the  left  tireteric  fold  in  view  the  instrument  is  withdrawn 
until  it  disappears  and  then  s\nmg  in  this  plane  over  toward  the  right, 
thus  completing  the  next  field-zone  of  the  trigonum  and  in  this  manner 
embracing  all  that  can  be  examined  with  the  axial  vision  cystoscope 
in  this  point. 

6.  The  cystoscope  is  now  returned  in  the  midplane  of  the  bladder 
until  the  plica  interureterica  disappears  from  the  field,  when  the 
process  of  swinging  the  instrimient  to  the  right  and  then  to  the  left  in 
the  same  plane  as  far  as  possible  is  repeated  and  the  lower  field-zone 
of  the  posterosuperior  segment  is  completed. 

7.  From  the  extreme  left  point  of  this  left  field-zone  the  instrument 
is  advanced  imtil  some  detail  at  one  margin  disappears  at  the  opposite 
margin  of  the  field,  when  the  instrument  is  made  to  traverse  from  left 
to  right  as  far  as  possible.  This  completes  the  second  field-zone  of 
this  segment  and  others  if  present  are  covered  in  the  same  manner. 

8.  At  this  point  on  the  extreme  right  the  objective  is  elevated  by 
depressing  the  eye-piece,  and  by  the  same  lateral  sweep  from  right  to 
left  is  made  to  cover  the  posterior  field-zone  of  the  subperitoneal 
segment. 

9.  With  further  depression  of  the  eye-piece  and  withdrawal  of  the 
instrument  until  a  landmark  at  once  disappears  at  the  opposite  margin 
of  the  field,  the  instrument  is  traversed  over  the  bladder  in  the  opposite 
direction  from  left  to  right,  thus,  as  a  rule,  completing  this  segment 
of  the  bladder;  otherwise  additional  duplicate  steps  will  do  so. 

10.  Again,  with  depression  and  withdrawal,  as  before,  the  posterior 
field-zone  of  the  retropubic  segment  of  the  bladder  is  reached,  and  with 
the  lateral  sweep  made  to  cover  it. 

As  a  rule,  no  more  of  the  bladder  than  this  can  be  examined  with  the 


INSPECTION,    LOCALIZATION,    ORIENTATION    OF   BLAUDER     1^1 

axial  vision  instrument  and  resort  must  therefon;  l)e  liad  to  the  retro- 
vision  telescope  of  the  lateral  field  instrument  or  to  the  cystourethro- 
scope  of  Buerger. 

Convex  Sheath  Close-vision  Cystoscope  and  with  the  Plan  of  Orientation 
of  the  Bladder  with  the  Cystourethroscope. — Of  the  various  instruments 
of  this  class  available,  the  cystourethroscope  perfected  by  Buerger  and 
the  Acmi  convex  sheath  close-vision  cystoscope  seem  to  be  the  most 
serviceable. 

The  Acmi  close-vision  cystoscope  permits  more  rotation,  being  liter- 
ally a  lateral  vision  instrument  with  a  close  field,  whereas  the  cysto- 
urethroscope requires  the  sweeping  technic  of  the  axial  vision  instru- 
ment, but  both  share  in  this  detail  somewhat. 

1.  The  instruments  are  inserted,  brought  to  the  middle  line,  over 
the  margin  of  the  trigonum,  along  which  their  fields  are  made  to  travel 
until  the  ureters  and  their  folds  have  been  studied. 

2.  With  the  same  detail  of  laying  out  field-zones,  previously  described, 
the  trigonum  is  studied  with  the  neck  of  the  bladder  at  the  trigonum, 
through  180  degrees. 

3.  The  instruments  are  then  rotated  upward  and  withdrawn  until 
the  neck  of  the  bladder  begins  to  occupy  the  field,  which  is  recognized 
by  its  brilliant  illumination  compared  with  the  less  distinct  bladder 
cavity  beyond.    The  neck  at  this  point  is  then  reviewed. 

4.  The  instruments  are  then  advanced  with  great  depression  of  the 
eye-piece,  so  as  to  bring  the  portion  of  the  urachal  segment  of  the 
bladder  into  view. 

There  is  no  reasonable  excuse,  therefore,  for  failure  to  cover  every 
portion  of  the  bladder  with  these  plans  of  procedure,  providing  for  the 
application  of  the  laterovision  cystoscope  with  the  retrograde,  recto- 
grade  and  anterograde  telescopes,  of  the  axial  vision  cystoscope,  and 
finally  of  the  close  vision  convex  sheath  cystoscope  and  of  the  cysto- 
urethroscope. 

It  will  be  at  once  realized  that  where  the  imaginary  transverse 
vertical  plane  of  the  bladder  meets  the  walls  a  right  and  left  meridian 
are  outlined,  and  that  where  the  imaginary  horizontal  plane  crosses 
the  bladder  a  line  which  should  be  called  the  equator  of  the  bladder  is 
laid  down.    And  that  neck  and  apex  are  the  lower  and  upper  poles. 

These  designations,  as  previously  stated,  are  referred  to  the  ana- 
tomical position  which  is  erect  and  at  90  degrees  to  the  reciunbent  or 
cystoscopic  position.  Therefore  in  the  latter  the  transverse  vertical 
plane  and  the  meridians  are  horizontal  while  the  horizontal  plane  and 
the  equator  are  vertically  placed.  No  confusion,  however,  need  arise 
if  a  little  care  is  exercised  until  one  is  familiar  with  this  geography  of 
the  viscus  as  it  might  be  called. 

This  method  of  exammmg  the  bladder  is  not  so  laborious  as  the 
written  description  might  suggest.  It  omits  nothing  and  also  permits 
reasonably  accurate  charting  of  the  point  of  the  lesion.  If  we  consider 
that  three  field  zones  commonly  cover  each  quadrant  it  is  possible,  for 
example,  to  describe  a  lesion  as  situated  "  in  the  lower  posterior  quad- 


748  THE  BLADDER 

rant,  inidilk'  firld  zone,  (10  dt\ii;reos  to  the  left  and  extending::  to  DO 
deiiives,  and  reaehinir  a  dianu'ttT  of  two-thirds  of  a  foeal  field." 

Examination  of  the  Vesical  Mucosa  as  a  Whole  in  Cystoscopy  respeets 
the  foUowinii:  features:  eolor.  \essels,  jj;loss,  eontinnity,  edema,  elas- 
ticity, iie\v  i^rowth,  ideers,  foreijiii  bodies  and  eontents,  sneh  as  urine, 
blood,  nuieus  and  ])us. 

1.  Color  of  the  niueosa  varies  witli  health,  illumination  and  disease. 
In  lualth  it  should  be  whitish  with  an  admixture  of  yellow  and  red  of 
moderate  decree  throughout  the  whole  of  the  bladder  exeept  the  trifi;o- 
num.  where  a  dull  positi\e  redness  exists  thr(»uj;ii  j;reat  vaseularity. 

Illumination  when  white  and  intense  and  when  close  to  the  surface 
decreases  the  yellow-red  tone  but  when  itself  less  white  and  strong  or 
more  remote  from  the  field  increases  it.  With  light  of  known  quality 
and  intensity  it  is  a  good  diagnostic  ])ouit  to  approach  and  recede  from 
the  mucosa  to  notice  whether  the  color  so  changes.  If  the  redness  is 
much  the  same  inflammation  is  present. 

In  disease  the  color  becomes  paler  in  anemia  l)ut  deeper  in  all  con- 
ditions of  congestion  and  inflammation. 

2.  Bloodvessels  in  the  bladder  are  in  normal  cases  outlined  well 
against  their  annexa  in  the  mucous  membrane  much  like  the  rivers  in 
school  geographies.  The  arteries  are  smaller  and  redder  than  the  veins 
and  may  occasionally  be  seen  to  pulsate.  In  the  trigonum  the  vessels 
may  no  longer  be  distinguished  from  each  other  owing  to  the  close 
mass  of  the  capillaries  in  this  region  and  the  resultant  somewhat 
miiform  dull  redness.  These  capillaries  may,  however,  be  recognized 
as  interlacing  in  health.  With  circulatory  obstruction  varices  of  the 
bladder  may  be  present  and  interesting;  in  anemia  the  vessels  may  be 
difficult  to  recognize,  and  in  atrophic  bladders  they  may  be  practically 
absent  in  the  cystoscopic  field. 

3.  Gloss  of  the  epithelimn  of  the  bladder  is  in  health  unmistakable 
and  resembles  that  seen  in  other  mucous  membranes  although  not  of 
high  degree.  It  is  best  perceived  by  changing  from  the  normal  to  the 
oblique  field  wth  rotation  of  the  instrument.  Congestion,  inflamma- 
tion and  circulatory  obstruction  result  in  swelling,  edema  and  loss  of 
gloss,  disseminated  universally  or  in  patches  here  and  there. 

4.  Continuity  of  mucosa  in  the  bladder  implies  absence  of  any 
breaks  in  the  surface  either  by  ulcers,  erosions  or  zones  of  inflammation. 
It  is,  therefore,  in  milder  degrees  analogous  to  gloss.  In  higher  degrees, 
however,  it  implies  actual  loss  of  substance,  superficially  or  deep. 

5.  Edema  of  the  bladder  lining  is  that  actual  swelling  of  the  mucosa 
which  invariably  implies  inflammation  or  great  vascular  obstruction. 
It  may  occur  over  the  bladder  wherever  in  view  or  only  in  scattered 
areas,  few  or  many  in  number,  or  as  a  special  form  called  bullous 
edema. 

6.  Elasticity'  of  the  bladder  walls  is  synonymous  with  its  muscular 
action  and  distensibility.  Muscular  contraction  manifests  itself  by 
the  appearance  and  disappearance  under  the  eye  of  fine  fibrillar 
trabeculations,  in  the  midst  of  previously  smooth  mucous  membrane. 


INSPECTION,    LOCALIZATION,    ORIENTATION   OF   BLADDER     749 

With  the  fixed  trabeculatioiis  of  the  hypertr(>i>hie(l  blu(l(Jer.s  in  tiie 
chronic  cystitis  of  prostatism  and  urethral  stricture,  muscular  action 
accentTiates  the  baJids  and  f]('(']K'ns  the  pockets,  which  are  harder  than 
before  to  illuminate.  Disteiisibility  of  the  bladder  has  no  effect  on  the 
latter  but  usually  corrects  the  former  much  as  it  does  those  folds 
which  appear  before  the  bladder  is  completely  filled. 

7.  New  growths  in  the  bladder  wall  receive  attention  as  to  the 
quadrant  and  zone  of  their  location,  their  number,  size  anrl  form,  their 
sessile  or  pedunculated  attachment,  their  vascularity  and  hemorrhagic 
tendency,  their  unbroken  or  broken  and  sloughing  surface,  and  their 
annexa. 

8.  Ulcers  and  excavation  of  the  vesical  mucosa  are  similarly  described 
as  to  location,  number,  size,  outline,  floor,  edges,  vascularity  and 
annexa,  especially  in  tuberculous  ulcers  which  frequently  have  numer- 
ous tubercles  in  their  neighborhood. 

9.  Foreign  bodies,  including  calculi,  gravel,  masses  of  mucus  and  pus 
and  exfoliated  epithelium  in  the  bladder,  are  studied  in  the  same  way 
as  to  location,  number,  size,  outline,  fixity  and  effect  on  the  surrounding 
mucosa.  Fixity  had  best  be  tested  with  a  ureteral  catheter  or  other 
instrument. 

10.  Contents  of  the  bladder  in  cystoscopy  of  importance  are  blood, 
pus  and  mucus  and  should  be  noted  as  to  source,  rapidity  of  appear- 
ance, amount,  fluidity  or  clotting  and  thickening,  and  adhesiveness. 
The  chief  sources  are  the  ureters,  the  mucous  membrane  and  the  neck 
of  the  bladder. 

Anatomical  Subdivisions  of  the  Bladder  in  Cystoscopy. — Having 
completed  the  general  features  to  be  borne  in  mind,  we  next  consider 
the  chief  anatomic  subdivisions  of  the  bladder  requiring  study,  namely: 
the  neck,  the  trigone,  the  ureteral  openings,  the  base,  the  fundus,  the 
lateral  walls  and  the  vertex  or  apex. 

1.  Neck  of  the  Bladder. — The  vesical  outlet  is  not  funnel-shaped  but 
rather  flattened  at  the  small  dimple  in  the  center  of  a  closed  sphmoter 
muscle.  As  one  withdraws  the  cystoscope  the  roof  and  sides  of  the 
neck  cross  the  field  as  a  curtain,  while  the  floor,  in  both  sexes,  is  less 
distinctly  demarked  from  the  rest  of  the  viscus,  owing  to  the  fact  that 
the  muscle  is  at  this  point  more  fixed  by  the  prostate  in  the  male  and 
the  vagina  and  cervix  uteri  in  the  female.  With  brilliant  illumination 
the  mucosa  of  the  roof  and  sides  is  translucent  and  the  normal  longi- 
tudinal folds  created  by  the  muscles  look  almost  like  poh-pi  but  are 
distinguished  from  them  by  being  broadly  sessile  and  not  pedunculated, 
by  having  no  bloodvessels  of  prominence  entering  them,  by  having 
no  mucous  strings  attached  to  them,  by  changing  their  form  with 
muscular  action,  and  by  gradually  merging  into  the  surrounding 
mucosa.    They  are  not  signs  of  disease  at  all. 

2.  Trigone. — This  anatomical  part  is  the  anterior  segment  of  the 
floor  of  the  bladder  extending  from  the  urethra  to  the  ureters.  The 
former  marks  its  apex,  the  latter  the  angles  of  the  base  and  the  mter- 
uteric  fold  comprises  the  base  itself,  as  a  rule  about  3  cm.  in  length. 


750  THE  BLADDER 

In  the  sittlni;  posture  the  triiri)ne  recedes  helow  the  horizontal  ])lane  a 
little,  while  in  the  reennibent  ])osition  this  angle  is  nearly  45  degrees. 
AVhen  the  ureters  are  reached  the  floor  of  the  bladder  again  droops 
backward  a  little  into  a  secondary  pouch  of  shallow  de])th,  unless  the 
plica  interureterica  and  the  courses  of  the  ureters  through  the  bladder 
wall  are  unusually  i)roniinent,  when  the  dei)th  of  this  droop  may  be 
considerable  and  easily  hari)(>r  small  stones,  especially  near  the  ureter. 

The  vascularity  of  the  trigoniun  is  so  marked  that  individual  vessels 
can  hardly  be  distinguished  and  that  the  color  is  a  low,  more  or  less 
uniform,  red.  This  {)art  of  the  bladder  is  elevated  slightly  above  the 
surrounding  level  of  the  viscus  and  is  convexed  in  contour  by  the 
prostate  in  the  male  and  the  cervix  uteri  in  the  female.  Its  surface  is 
ordinarily  smooth,  although  one  gains  the  impression  that  the  mucous 
membrane  is  not  quite  so  firmly  attached  as  elsewhere  in  the  bladder. 
Clo.se  to  the  neck  longitudinal  and  radially  arranged  rugie  or  folds 
appear  leading  from  the  neck  and  ])roduced  by  the  purse-string 
action  of  the  cut-ofi'  muscle  where  it  is  looser  than  a  little  farther 
back. 

Deformations  of  the  trigone  proceed  chiefly  from  its  annexa  and 
vesical  disease.  In  the  male  the  i)r()state  and  seminal  vesicles,  and 
in  the  female  the  vaginal  wall  in  cystocele,  and  the  neck  and  bod>'  of  the 
uterus  through  displacements  and  descent,  may  di.stort  the  trigonum 
into  any  conceivable  form,  position  and  direction.  Similarly  the  scars 
and  infiltrations  of  inflammation  and  other  disease  ma>-  also  render  it 
recognizable  witli  difficulty. 

:>.  Mouths  of  the  Ureters. — The  course  of  the  ureters  through  the 
bladder  wall  is  from  behind  forward,  inward  and  downward  so  that 
where  they  meet  the  wall  of  the  bladder  their  openings  are  necessarily 
oblique  through  the  angidar  relation  of  their  axis  to  the  vesical  surface. 
The  normal  meatus  of  the  ureter  resembles  very  closely  in  miniature 
the  vulva  of  an  infant,  the  slit  of  the  meatus  is  directed  from  behind 
forward  and  inward  and  the  lips  are  commonly  in  close  apposition  unless 
opened  during  the  discharge  of  urine. 

The  ureteral  meatuses  are  situated  at  each  angle  of  the  base  of  the 
trigonum  at  the  average  distance  of  2  cm.  (1  cystoscopic  fiekl)  l^ehind 
the  urethra,  at  an  interval  of  separation  of  3  cm.  (a  little  more  than  a 
cystoscopic  field),  and  in  size  average  2.5  mm.  They  are  usually 
connected  by  the  plica  ureterica  as  it  forms  the  base  of  the  trigonum 
and  the  continuation  of  the  prominences  in  the  bladder  ^\■all  made 
by  the  ureters  in  their  course  through  it.  The  plica  may  be  scarcely 
discernible  or  may  be  so  prominent  as  to  constitute  a  real  ridge  in  the 
bladder  floor  forming  the  anterior  border  of  a  shallow  pocket  behind 
it.  In  these  cases  the  ureteral  mouths  are  elevated  considerably  so  as 
to  resemble  somewhat  small  nipples  with  relatively  large  openings. 
In  other  bladders  the  mouths  are  level  with  the  floor  and  at  times 
difficult  to  find. 

The  landmarks  of  the  ureteral  outlets  are  the  ])lica  ureterica  and  the 
posterior  border  of  the  dull  red  trigonum.     If,  as  previously  stated, 


INSPECTION,   LOCALIZATION,    ORIENTATION   OF   BLADDER     751 

the  air  bubble  in  the  vault  of  the  bladder,  usually  at  its  highest  point 
in  the  middle  line,  is  surely  recognized,  and  the  instrument  rotated 
through  180  degrees  to  the  middle  line  of  the  floor  of  the  bladder, 
slight  increased  or  decreased  penetration  of  the  cystoscope  will  soon 
locate  either  of  these  two  landmarks.  The  field  is  then  marlo  to  travel 
with  each  landmark  across  its  middle— a  manipulation  which  almost 
immediately  locates  the  ureters. 

The  form  of  these  openings  resembles,  as  stated,  the  infant  vulva 
but  should  always  be  studied  under  a  rotating  cystoscope.  In  other 
words,  it  is  best  to  get  the  instrument  directly  over  the  ureter  and  care- 
fully focussed  and  then  to  rotate  it  in  order  to  obtain  a  lateral  view 
also,  which  will  permit  judgment  of  elevation,  excavation,  patency  and 
other  disease  processes.  Occasionally  a  bit  of  the  lining  of  the  ureter 
at  the  mouth  may  be  seen  especially  with  the  newer  models  of  close 
vision  instruments  such  as  the  Buerger  cystourethroscope,  the  Pilcher 
and  Acmi  convex  sheath  cystoscopes. 

The  vascularity  of  the  ureters  is  important  in  that  commonly  a 
bloodvessel  of  considerable  size  emerges  from  the  mouths  or  close  to 
them.  About  once  in  two  or  three  minutes  the  healthy  ureteral  mouth 
will  open  through  muscular  action  and  discharge  urine,  the  quantity, 
quality,  direction  of  flow  and  distinctness  of  which  should  be  carefully 
noted  and  compared  with  the  opposite  ureter.  If  the  urine  is  consider- 
ably heavier  than  the  distending  medium  it  will  usually  flow  along 
the  floor  first,  which  in  the  inverted  image  instruments  appears  to  be 
backward  and  upward  instead  of  forward  and  downward,  as  in  the  erect 
field  cystoscopes — a  distinction  which  must  be  familiar  to  the  operator. 
The  quantity  of  urine  at  each  evacuation  is  usually  2  or  3  c.c,  the 
normal  quality  is  clear  unless  blood,  pus  and  detritus  are  present  and 
the  distinctness  of  the  flow  depends  upon  the  comparative  color  as  the 
urine  enters  the  medium. 

The  patency  of  the  ureteral  openings  is  important  and  varies  from 
the  normal,  somewhat  firm,  apposition  of  the  little  lips  in  health,  to 
the  gaping  "golf  hole"  meatus  of  tuberculosis,  and  the  irregular  dis- 
tortions of  form  due  to  prostatic  and  uterine  disease,  for  example. 

The  diameter  of  the  ureteral  openings  is  in  adults  rarely  over  7  F. 
and  may  be  5  F.  or  4  F.  and  in  children  proportionally  smaller.  There 
frequently  is  a  difference  between  the  two  sides  so  that  one  ureter 
may  receive  the  7  F.  catheter  and  its  fellow  one  of  smaller  caliber. 

The  act  of  locating  the  ureters  in  health  is  easy  with  any  standard 
telescope,  whether  direct  field  or  indirect  field  of  the  lateral,  retrograde 
or  anterograde  types.  If,  however,  the  floor  of  the  bladder  is  deformed, 
the  openings  of  the  ureters  may  be  most  diflEicult  to  fix  satisfactorily 
in  the  field.  The  convexity  of  the  floor  due  to  the  prostate  or  uterus 
frequently  requires  the  retrograde  telescope  with  the  instrument  pene- 
trated to  considerable  degree.  Sometimes  the  lateral  lobes  of  the  pros- 
tate suggest  a  close  vision  instrument ;  thus  the  effort  to  find  these  very 
important  structures  must  not  be  abandoned  until  all  ordinary  means 
have  been  exhausted.    Additional  distention  of  the  bladder  or  change 


752  THE  BLADDER 

in  tlie  position  of  the  ])ati(.Mit  will  often  i)erniit  stndx-  of  nreters  pre- 
viously ont  of  view. 

Inflaniniation  of  the  i)la(l(ler  may,  through  diffuse  redness  and 
etlenia,  mask  all  tiie  landmarks  of  the  ureteral  o])enings.  The  operator 
should  then  place  his  field  at  the  api)roximately  correct  i)oint  and  wait 
for  the  (lischar^(>  of  urine  to  make  the  diagnosis.  It  may  even  he  neces- 
sary to  adniinistiM-  indigocarminc"  or  other  d\'e  to  facilitate  this  ])rocess. 

Changes  in  the  Form,  Size  and  Surface  of  the  Normal  Vesical  Cavity. — 
The  form  of  the  Madder  \aries  more  frecjuentlx'  in  females  than  in 
males  through  tin-  hulging  of  the  rectum  in  the  chronic  constipation  to 
whicli  women  are  so  subject,  through  the  wide  variations  in  the  si/,e, 
form  and  position  of  the  uterine  body  and  cer\-ix,  and  through  the 
common  diseases  of  the  annexa.  Any  of  these  may  change  the  form  of 
the  cavity  from  any  direction.  In  males  the  prostate  and  seminal 
vesicles  have  a  similar  infiuence,  chieHy,  however,  from  the  floor  oidy 
and  slightly  lateral.  In  both  sexes  tlie  infantile  or  conical  form  of 
bladder  may  persist  so  that  it  is  very  difficidt  to  reach  and  examine  the 
apex.    In  childhood  this  is  one  of  the  difficulties  regularly  encountered. 

The  size  of  tlie  bladder  in  women  is  greater  than  in  men,  from  a  third 
part  to  a  half-cai)acity,  so  that  discomfort  begins  in  the  female  at  300  c.c. 
and  in  the  male  at  200  c.c.  The  extreme  limits  of  bladder  capacity  may 
be  as  little  as  100  c.c.  or  as  great  as  1000  c.c.  without  valid  anatomical 
explanation  except  actual  embryological  development. 

The  surface  of  the  vesical  interior  varies  according  to  the  ])ortion 
observed.  The  trigonum  may  be  elevated  through  anatomical  struc- 
ture or  convexed  through  extravesical  organs,  especially  the  prostate 
and  the  uterus.  The  ureteric  and  interureteric  folds  may  be  unusually 
prominent,  even  forming  shallow  pouches  commonly  posterior,  some- 
times anterior  to  them.  Trabeculations  may  make  the  surface  of  the 
bladder  une\'en  and  are  of  two  forms:  the  permanent  and  the  tem- 
porary. The  latter  are  seen  in  youth  and  are  due  either  to  anatomical 
muscidar  arrangement  or  momentary  action  across  the  field  of  vision. 
The>'  are  distinguished  from  fixed  trabeculations  by  the  fact  that  the 
muco.sa  is  normal,  and  the  irregularities  disappear  under  distention  and 
change  their  arrangement  and  relation  under  the  observing  eye.  Per- 
manent trabeculations,  on  the  other  hand,  mark  the  bladder  of  old  age, 
of  prostatitis  and  of  urethral  stricture,  through  the  chronic  cystitis 
commonly  present  in  all  these  states.  The  mucosa  in  these  cases  is 
therefore  unhealthy,  the  trabecuhe  large,  ])rominent,  unchanging  and 
separated  from  each  other  by  pouches  of  various  depths  which  are 
difficult  to  illuminate.  Distention  and  muscular  action  make  these 
trabeculiie  more  a])parent. 

Pouches  iji  the  wall  of  the  bladder  ma>'  represent  true  or  false  diver- 
ticula. True  diverticula  are  actual,  anatomical  abnormalities,  are  not 
removed  by  distention,  have  no  trabecule  bordering  their  mouths,  are 
usually  imassociated  with  cystitis,  vary  within  narrow  limits  as  to  the 
size  and  form  of  their  mouths,  and  ma>'  be  ex])l()red  with  the  cystoscope 
as  individual  pouches  offset  from  the  bladder.    False  dixerticula  of  the 


INFLAMMATIONS  AND  INFECTIONS  753 

bladder  are  really  pouches  of  larj^e  size  associated  with  extrerri(,'  trabecu- 
lation  and  are  therefore  small  herniations  of  the  bladder  wall  between 
the  trabecule,  unaltered  by  increased  distention  except  to  accentuate 
their  characteristics.  True  diverticuhi  may  be  seen  to  distend  uni- 
formly with  the  bladder  in  many  cases.  One  form  of  false  diverticula 
occurs  in  nervous  subjects  by  a  muscular  wave  which  will  gather  the 
bladder  into  an  upper  and  lower  segment  with  a  more  or  less  narrow 
isthmus  between  and  with  little  or  no  illumination  of  the  uy)per  seg- 
ment— a  kind  of  hour-glass  condition.  The  writer  has  had  one  such 
case  which  disappeared  under  patience  and  increased  distention. 

II.  THE  DISEASED  BLADDER. 

'  INFLAMMATIONS  AND  INFECTIONS. 

General  Principles. — The  universal  law  of  all  mucous  membrane 
applies  to  the  urogenital  tract  as  everywhere  else  in  the  body,  namely, 
that  it  cannot  be  diseased  beyond  certain  narrow  limits  without 
suffering  damage  above  the  power  of  man  or  Nature  to  cure.  Practi- 
cally all  diseased  process  in  the  bladder  expresses  itself  as  mflammation 
of  various  degrees,  beginning  with  simple  hyperemia  and  ending  with 
acute  destructive  and  chronic  productive  forms.  The  mildest  forms 
of  cystitis  are  therefore  evanescent  hyperemias  which  may  not  even 
reach  the  stage  of  obliterating  the  individual  bloodvessels  under  the 
cystoscope.  More  intense  cystitis  is  accompanied  by  exfoliation  of 
epithelium,  the  exudation  of  pus  and  mucus,  the  masking  of  blood- 
vessel outlines  and  submucosal  or  supramucosal  hemorrhage.  The  most 
severe  inflammation  of  the  bladder  extends  exfoliation  of  epithelium 
to  necrosis  so  that  superficial  or  deep  ulcers  occur  and  cicatrization 
represents  their  healing,  which  may  be  followed  by.  chronic  productive 
inflammation. 

The  action  of  the  urine  on  the  diseased  mucous  membrane  is  not 
beneficial  inasmuch  as  the  same  factors  which  infect  this  tissue  also 
change  the  urine  in  its  chemical  composition,  reaction  and  specific 
gravity.  Thus  substances  which  are  normally  in  solution  in  the  urine 
precipitate  out,  notably  phosphates  in  alkaline  urines,  urates  and  uric 
acid  in  acid  urines.  Such  deposits  may  lie  upon  the  floor  of  the  bladder 
as  mechanical  irritants,  or  by  combining  with  plugs  of  pus  and  mucus 
form  the  nuclei  of  calculi,  which  by  pressure  and  attrition  only  augment 
the  inflammatory  process.  Cautions  of  instrumentation  of  the  diseased 
bladder  comprise  the  following  rules : 

1.  The  fewest  possible  invasions — one  instrument  for  the  greatest 
number  of  purposes  being  best. 

2.  Urine  should  be  in  the  bladder  in  inflammation  and  nervousness 
to  avoid  irritation  of  the  walls  with  the  instruments. 

3.  Irrigation  of  the  bladder  should  be  done  with  small  quantities, 
gently  and  frequently  repeated,  of  bland,  unirritating  solutions  under 
easy  and  full  evacuation  and  never  to  the  pomt  of  pain  or  distress. 

48 


754  THE  BLADDER 

4.  If  the  ])ationt,  esiiecially  a  male,  has  never  had  a  metal  instru- 
ment passed  tln-ough  tlie  urethra  the  first  invasion  liad  best  be  done 
with  a  soft-rubber  catheter. 

From  the  foregoing  principles  it  follows  that  whenever  conditions 
permit,  the  cystoscope  alone  should  be  gently  introduced  while  the 
bladder  contains  urine,  which  is  easily  cA'acuated  at  the  withdrawal  of 
the  obturator.  The  cavity  may  next  be  Hushed  through  the  empty 
sheath  if  the  vigor  of  this  method  is  not  contra  indicated;  or  the  tele- 
scope may  be  seated  and  then  the  irrigation  ])roceed  through  the  inlet 
and  outlet  faucets.  Finally  the  desired  degree  of  distention  is  secured 
and  the  cystosco])y  proper  begun.  During  these  stei)s  the  cystoscoi)e 
should  be  held  as  much  at  rest  as  possible  with  the  fenestrum  away 
from  the  bladder  floor  to  avoid  excoriations.  This  is  ordinarily  })ref- 
erable  to  the  "two  journey"  ])lan,  called  for  by  the  nonirrigating 
cystoscopes  which  require  all  preparation  of  the  bladder  to  be  done 
with  a  catheter  first.  Sometimes  this  extra  manipulation  induces 
spasm  of  the  sphincter  difficult  to  overcome. 

Varieties  of  Vesical  Pathology  include  anatomical  abnormalities, 
inffannnations,  neoplasms,  tramnatisms  and  concretions.  Deviations 
from  the  anatomical  normal  of  the  l)la(lder  may  involve  any  part  of 
this  viscus  or  of  the  ureters.  The  inflammations  may  follow  the  type 
of  general  purulent  infections  of  which  that  due  to  the  Bacillus  coli  is 
common  and  momentous,  or  the  type  of  specific  invasions  of  which 
tuberculosis  is  always  in  mind.  Neoplasms  include  benign  forms  such 
as  vesical,  cysts  and  fibromata,  and  malign  varieties  such  as  cancer  in 
all  manifestations.  Vesical  trauma  embraces  mechanical  damage 
incidental  to  accident  and  operation  which  is  frequently  encountered; 
thermal  injury  through  scalds  of  too  hot  irrigations,  which  are  rarely 
seen ;  and  finally,  chemical  burns  through  concentrated  solutions,  which 
are  likewise  uncommon.  Concretions  is  a  term  implying  all  forms  of 
calculi  in  the  bladder  of  various  number,  size  and  composition  including 
plugs  of  mucus  and  pus  as  Avell  as  precipitates  from  the  urine. 

Areas  and  Extensions  of  Vesical  Lesions,  strange  to  say,  follow  almost 
regularly  the  subdivisions  of  this  viscus  recognized  for  anatomical 
descri])tion,  usually  in  the  following  order:  neck,  trigonum,  floor 
behind  the  trigonum,  ureteric  openings  at  the  angles  of  its  base,  fundus, 
parietes  and  apex.  A  single  small  or  large  area  of  the  mucosa  may  be 
inflamed  or  similar  spots  may  be  scattered  e^'erywhere,  while  the 
remaining  parts  are  absolutely  or  comparatively  healthy.  One  or  more 
zones  of  mflammation  may  be  undergoing  resolution  while  others  are 
still  in  the  acute  or  hyperacute  stage.  If  the  bladder  becomes  inconti- 
nent and  collapsed  into  folds,  previously  healthy  portions  become 
infected  by  apposition  with  foci  of  disease.  Thus  the  infection  may 
extend  by  contiguity  as  well  as  by  continuity  along  the  surface  of  the 
epithelium,  or  through  the  lymphatic  and  bloodvessels  when  the 
bladder  does  not  lose  its  containing  power. 

Sources  of  Error  in  Cystoscopy. — The  normal  l)ladder  as  contrasted 
with  the  diseased  \'iscus  ma}-  lead  to  mistakes  through  such  simple 


INFLAMMATIONS  AND  INFECT  ION  H  755 

factors  as  distention,  illumination,  deformation,  dye-stainerl  urine, 
mucosal  reduplications  and  the  like. 

Distention  in  cystoscopy  is  so  much  a  matter  of  habit  that  it  is  well 
for  the  operator  to  become  skilled  in  the  appearance  of  the  normal 
bladder  during  collapse  or  at  least  during  partial  distention.  In  these 
circumstances  the  vessels  will  be  foimd  of  apparently  wider  caliber 
and  more  numerous  so  as  to  redden  the  general  color,  ^fhe  gloss  of 
the  mucous  membrane  is  also  less  because  of  less  tension  exerted  on  it. 
Decreased  size  of  the  bladder  cavity  in  partial  distention  brings  the 
mucous  membrane  nearer  the  objective  lens,  which  also  tends  to  redden 
the  general  color. 

Illumination  of  the  bladder  cavity  with  intense  white  light  brightens 
the  redness  to  a  distinct  whitish  or  yellowish  tone.  A  less  clear  light 
permits  a  deeper  red  to  prevail.  Inasmuch  as  the  intensity  of  the  light 
should  always  be  fixed  outside  the  bladder  it  is  not  advisable  to  change 
it,  excepting  to  decrease  it  and  then  return  to  the  original  point. 
Increase  in  the  current  after  the  lamp  is  in  the  bladder  usually  burns 
out  the  filament.  A  better  test  is  to  make  the  light  approach  and 
recede  from  the  field  in  judging  color. 

Objective  and  ocular  lenses  may  be  soiled  and  lead  to  error.  A 
layer  of  blood,  mucus,  pus  or  lubricant  on  the  objective  or  prism  may 
be  very  annoying  and  require  withdrawal  and  cleansing  of  the  telescope. 
A  most  important  preliminary  therefore  is  always  to  see  that  the  lenses 
are  clean. 

Normal  folds  of  the  bladder  wall  constituting  true  rugae  may  deceive 
unless  distention  is  employed  to  alter  their  forms,  and  the  ureteral 
catheter  to  test  their  attachment  and  depth. 

Muscular  bands  of  prominence  in  the  bladder  may  be  an  anatomical 
peculiarity  or  at  any  age  show  the  results  of  obstruction ;  in  youth  by 
stricture  and  in  old  age  by  prostatic  involvement.  As  already  pointed 
out,  changes  in  their  conformation  indicate  a  temporary  character  and 
absence  of  these  changes  the  permanent  form  of  trabeculation.  The 
condition  of  the  mucous  membrane  overlying  them  is  almost  always 
healthy  in  the  former,  but  diseased  in  the  latter  variety. 

The  course  of  the  ureters  through  the  bladder  wall  may  show  as 
definite  prominences,  the  plica  ureterica,  either  through  hypertrophy 
of  the  muscular  wall  of  the  ureters  or  simple  anatomical  size.  Such  are 
distinguished  from  diseased  conditions  by  the  absence  of  the  signs  of 
chronic  inflammation  in  the  mucous  membrane  over  these  promi- 
nences, of  abnormal  conditions  in  the  ureteric  mouths  and  of  the  dis- 
charge of  blood,  pus  or  mucus  with  the  urine.  A  ureteral  catheter 
passes  easily  and  without  any  obstruction  through  such  ureters. 

High  colored,  normal  urine,  rapidly  discharged  into  the  bladder  and 
the  urine  of  the  various  efficiency  tests,  especially  methylene  blue, 
indigocarmine,  and  phenolsulphonephthalem,  may  change  the  appear- 
ance of  the  mucous  membrane  and  require  caution  on  this  account 
while  in  use. 

Deformations  of  the  normal  bladder  cavity  by  pressure  from  without 


756  THE  BLADDER 

may  he  so  deceptive  as  to  require  corroborative  examination  tlirough 
the  bimanual  method  in  both  sexes,  concerning  the  prostate  in  men 
and  the  internal  sexual  organs  in  women. 

The  vesical  neck  may  present  imder  the  purse-string  action  of  the 
sphhicter  muscle  a  number  of  folds,  redu]>lications  or  tabs  of  consider- 
able size.  They  should  be  examined  and  their  nature  d(>termined  by 
the  retrograde  telescoi)e,  the  cystoiu'ethrosct)i)e  and  palpation  with 
the  ureteral  catheter  or  other  instrument.  They  have  no  signs  of 
inflammatory  change  cither  as  hyperemia,  thickening  or  exfoliation. 

Orthopathologic  Changes. —  This  term  is  used  to  classify  and  in  a 
broad  way  describe  the  true  })athological  changes  to  which  the  blad<ler 
is  subject  as  the  expression  of  disease,  and  to  disthiguish  them  from 
those  conditions  in  health  as  just  described  which  may  closely  simulate 
disease. 

Location  of  Pathological  Change. — The  nuicosa  as  a  whole  or  in  dis- 
seminated areas,  the  muscularis  in  its  entirety  or  in  definite  regions, 
either  or  both  ureteral  meatuses  and  their  annexa  are  the  commonest 
sites  of  disease,  mdividually  or  in  complex  association  with  one  another. 
(^ystoscopic  pictures  or  objective  si/niptoms  are  more  or  less  similar  in 
character  but  A'ary  in  degree  as  they  accompany  inflammation,  neo- 
plasm, traumatism,  foreign  body  and  vascular  and  lymphatic  obstruc- 
tion. The  present  section  will  therefore  deal  with  the  manner  in  which 
the  bladder  sho\AS  reactions  to  these  conditions  in  a  general  way,  while 
a  descri])tion  of  the  particular  signs  of  certain  diseases  will  be  left  to 
appropriate  subsequent  sections. 

Reactions  in  the  mucosa  through  disease  may  be  classified  as  anemia, 
active  liA'peremia,  passive  h^'peremia,  submucosal  hemorrhage,  edema 
bullosa,  and  vesicle  and  cyst  formation. 

1.  General  Anemia  and  Ischemia  or  localized  anemia  of  the  mucosa 
are  not  xevy  common,  especially  the  latter.  Of  either  gradual  or 
sudden  development  they  denote  partial  or  complete  interference  with 
circidatory  function.  The  cause  is  mechanical  pressure  or  vasomotor 
results  of  cerebrospinal  disease.  Positive  and  more  extreme  anemia  is 
commonly  arterial  and  shows  as  focal  or  general  pallor,  whereas  the 
venous  forms  are  congestive  and  livid,  rapidly  passing  into  passive 
hyperemia.  If  the  process  of  arterial  anemia  progresses,  degeneration 
and  exfoliation  of  the  epithelium  ensue  with  necrosis  and  ulceration 
as  later  developments.  In  the  cystoscopic  field  these  various  condi- 
tions are  characteristic  and  relatively  easy  to  discern,  inasmuch  as 
universal  anemia  is  very  rare,  except  as  the  accompaniment  of  condi- 
tions which  would  lead  one  to  expect  it;  for  example,  as  the  result  of 
severe  hemorrhage,  of  systemic  anemia,  and  of  the  atrophy  of  the 
mucosa  through  the  capillary  arteriosclerosis  of  old  age.  Sudden 
obstruction  to  the  circulation  leads  to  momentary  anemia  followed  by 
submucous  ecch\Tnosis  and  hemorrhage,  which  shows  in  the  field  as  a 
very  deep  red  or  still  darker  spot,  darkest  where  the  process  is  oldest 
and  the  layer  of  blood  deepest.  Relative  anemia  of  the  bladder  may 
be  produced  by  overdistention  during  cystoscopy  and  may  be  distin- 


INFLAMMATIONS  AND  INFECTIONS  757 

guished  from  essential  anemia  by  decreasing  the  amount  of  dist(!ndiiig 
fluid  under  the  eye. 

2.  Active  Hyperemia  of  the  vesical  mucosa  is  of  arterial  origin  and 
denotes  a  surcharge  of  blood  at  one,  several  or  all  zones  of  the  bladder. 
The  difl'erential  diagnosis  between  inflammation  as  such  and  hyper- 
emia is  in  essence  in  the  following  facts:  that  in  inflammation  the  degree 
of  circulatory  activity  is  greater;  that  the  mucosal  interarterial  spaces 
are  no  longer  normal;  that  exfoliation  of  epithelium  and  production  of 
exudate  are  regularly  present;  and  that  the  process  as  a  whole  does  not 
involve  the  blood  current  alone.  From  this  it  follows  that  hyperemia 
may  represent  the  initial  or  resolving  periods  of  inflammation.  The 
causes  of  active  hyperemia  are  the  same  as  those  of  inflammation  but 
of  milder  degree:  traumatic,  thermal,  chemical  and  bacterial.  Trau- 
matism really  includes  the  first  three  factors  but  is,  however,  a  term 
used  to  denote  mechanical  agents  such  as  surgical  instruments  during 
examination  and  operation,  the  accidents  of  life  and  childbirth. 
Thermal  elements  include  burns  from  cystoscopic  lamps  and  hot  irri- 
gating fluids  or  the  depression  of  cold  irrigating  media. 

Chemical  sources  of  hyperemia  are  more  common  and  rest  on  con- 
centrated strengths  of  nonirritating  and  various  solutions  of  irritating 
salts,  the  latter  much  the  more  commonly.  The  bichlorid  of  mercury 
in  most,  and  in  many  bladders  potassium  permanganate  and  silver 
nitrate,  unless  in  weak  solutions,  are  familiar  examples  of  irritating 
salts,  applied  during  irrigation.  It  is  best  always  to  use  no  bichlorid 
and  the  weaker  percentages  of  the  other  two,  as  1  in  20,000  to  1  in 
10,000  for  the  first  trials.  Drugs  by  ingestion  may  cause  hyperemia, 
especially  the  newer  preparations  which  liberate  formaldehyde.  With- 
drawal of  the  offending  medicament  is  the  indication. 

The  arterial  hyperemia  caused  by  mechanical  and  chemical  means 
usually  does  not  go  on  to  inflammation.  When,  however,  bacteria  are 
the  cause  of  hyperemia,  the  reverse  is  the  case  and  the  hyperemia  is 
only  the  first  stage  of  extensive  inflammation.  The  common  germs  of 
purulence  including  the  gonococcus,  Bacillus  tuberculosis.  Bacillus  coli 
and  Bacillus  typhosus  are  most  familiar.  The  degree  of  h^'peremia 
is  usually  high,  persistent,  progressive  and  widespread,  excepting  the 
bacfllus  tuberculosis  which,  at  least  at  first,  causes  patches  of 
hyperemia. 

The  distribution  of  arterial  hyperemia  is  over  any  one,  few  or  many 
points  or  zones  of  the  bladder  wall,  or  generalized  everywhere.  The 
zones  are  attacked  in  the  order  of  frequency  as  follows :  the  trigonum 
and  base  in  the  cases  due  to  ordinary  causes,  the  vault  and  sides  from 
contact  with  instruments  or  cystoscopic  lamps,  and  the  mouths  of  the 
ureters  in  renal  and  ureteral  affections,  predominately  suppuration, 
tuberculosis,  lithiasis  and  neoplasm. 

Cystoscopic  pictures  of  arterial  hyperemia  show  the  minute  arterioles 
increased  in  number  and  enlarged  in  size,  approaching  the  diameter 
of  many  vessels  constantly  in  the  field  in  normal  bladders.  The 
mucous  membrane  over  the  areas  between  the  prominent  vessels  is 


758  THE  BLADDER 

fully  or  nearly  normal  witlumt  dulness,  exfoliation,  exudate  or  more 
than  slight  reddening  of  the  usual  color  tone. 

3.  Passive  Hyperemia,  Venous  Hyperemia  and  Venastasis  of  the  Vesical 
Mucosa  are  praetieally  synonymous  terms  and  are  conditions  due  to 
l)ressure  on  veins  with  resulting  distention  of  the  venules,  as,  for 
example,  by  the  uterus  enlarged  through  pregnancy  and  fibroid  tumors 
anil  by  pelvic  exudates  and  ne()])lasms,  ])hlebitis  and  thrombosis. 

The  cystoscopic  pictin-e  of  \cmious  hyperemia  is  that  of  various 
degrees  of  cyanotic,  imhealthy,  swollen  and  edematous  mucosa. 
\  arices  of  little  or  considerable  prominence  may  be  i)resent.  This 
condition  can  never  be  any  but  localized  to  the  area  drained  by  a  given 
system  of  veins  affected.  Sometimes  one  of  the  earliest  signs  of  car- 
cinosis of  the  prostate  is  a  venous  hyperemia  in  its  neighborhood. 

4.  Submucosal  Hemorrhage,  Ecchymosis  and  Petechise  of  the  Vesical 
Mucosa  denote  descending  grades  of  bleeding  into  the  intramucosal 
and  submucosal  tissues,  which  accompany  the  severer  degrees  of 
either  active  or  passive  hyperemia. 

In  the  cystoscopic  jjicture  they  are  large,  small  or  minute  extravasa- 
tions whose  redness  depends  on  the  recency  and  the  i)enetration  of  the 
process. 

5.  Edema  or  Serous  Effusion  of  the  Vesical  Mucosa  usually  follows  high- 
grade  hyi^eremia  as  the  second  stage  of  inflammation,  but  in  fulminat- 
ing cases  may  precede  it  as  the  first  stage  of  the  process,  exactly  as  is 
the  case  in  all  other  mucous  membranes.  The  pathogenesis  is  the 
effusion  of  serum  from  the  blood  into  the  subepithelial  and  submucosal 
layers,  and  the  exciting  causes  of  all,  those  of  the  hyperemias,  to  which 
should  be  added  severe  inflammation  in  the  neighborhood  of  the 
bladder.  More  or  less  lym])hatic  and  circulatory  obstruction  are  also 
underlying  factors. 

The  cystoscopic  picture  is  that  of  the  mucous  membrane  of  watery, 
succulent,  swollen  appearance,  with  a  tendency  to  "pitting"  under  the 
ureteral  catheters  and  usually  with  absence  of  bleeding  when  touched, 
unless  the  hyperemia  is  marked.  The  effusion  as  a-  rule  masks  the 
miderlying  small  bloodvessels  and  ecchymoses  unless  extensive.  The 
color  of  the  field  is  therefore  a  soggy  pale  one  unless  a  precedent  hyper- 
emia persists.  The  color  is  then  red  through  the  advancing  conges- 
tion, the  surface  raised,  uneven,  tense  and  glossy,  with  here  and  there 
polypoid  masses  of  translucent  pink,  and  few  bloodvessels. 

Causes  of  edema  additional  to  the  general  sources  of  hyperemia 
are  neo])lastic  changes  involving  the  blood  and  lymphvessels  along 
the  bladder  floor  through  deposits  in  the  uterus,  ])r()state  and  rectum. 
Pressure  of  impacted  ureteral  calculi  near  or  within  the  ^'esical  ])arietes 
may  extend  edema  along  the  plica  ureterica  mto  the  ureteral  meatus 
to  the  degree  of  total  occlusion.  Urethral  obstruction  from  stricture 
of  the  urethra  by  inflammation,  or  by  pressure  of  uterine  enlargement 
or  descent,  or  by  all  the  prostatic  diseases  may  cause  edema  at  the  neck 
of  the  bladder.  Great  irritation  of  the  mucosa  may  cause  edema,  as 
that  from  intense  changes  in  the  chemical  reaction  of  the  urine,  from  the 


INFLAMMATIONS  AND  INFECTIONS  759 

circulatory  effects  or  mechanical  damage  of  pressure  without  or  within 
the  bladder  in  tumors  and  lithiasis,  from  mechanical  obstruction  of 
stricture  and  prostatism,  and  finally  from  the  injury  of  accident  or 
incident  in  operation.  Inflammation  is  an  essential  anrl  regular 
accompaniment  of  edema. 

6.  Edema  Bullosum,  Edema  Hydatidiforme  vel  Edema  Vesiculosum  may 
be  defined  as  circumscribed  edema  with  formation  of  l)ulli(',  blebs  or 
vesicles  of  various  but  moderate  size,  closely  grouped  and  scjssilc,  or 
slightly  pedunculated  in  attachment.  The  condition  has  heen  regarded 
as  an  entity  but  is  probably  a  regular  accompaniment  and  sequel  of 
lymphatic  and  vascular  obstruction  of  high  focal  degree.  The  lesion 
occurs  more  commonly  in  females  than  in  males  and  is  caused  by  the 
circulatory  results  of  inflammation  and  pressure,  by  the  actual  weight 
of  enlarged  organs  as  the  uterus  and  the  prostate,  or  the  more  direct 
occlusion  of  inflammatory  exudate  and  infiltration.  It  is  therefore 
associated  with  hypertrophy  and  cancer  of  the  prostate,  uterus  and 
rectum,  the  intense  irritation  of  vesical  and  ureteral  stone,  the  chronic 
inflammatory  changes  of  tuberculosis  and  fistulse  and  the  intense 
reaction  of  hyperacute  cystitis,  as  all  these  conditions  affect  the  circu- 
lation of  both  lymph  and  blood. 

The  pathology  of  edema  bullosum  is  the  formation  of  serous  effusion 
in  the  mucosa  so  as  to  make  groups  of  vesicles,  greatly  or  moderately 
conjoined  into  single  or  several  masses.  The  limited  groups  corre- 
spond, no  doubt,  with  the  areas  in  relation  with  the  smaller  vessels 
affected,  be  they  the  radicals  of  lymphatics,  veins  or  arteries.  Thus 
the  blebs  may  be  remote  from  the  point  of  actual  compression  as  when 
an  early  cancer  of  the  prostate  excites  the  condition  in  the  trigonum. 

The  cystoscopic  picture  of  edema  bullosum  is  that  of  a  group  of 
blebs  resembling  a  closely  attached  bunch  of  grapes  or  half-capsules, 
distinctly  demarcated  from  its  annexa,  of  reddish-white  to  positive 
red  depending  on  the  amount  of  congestion  present,  of  elevated  uneven 
surface,  of  moderate  translucency  and  of  variable  congestion.  If 
the  lesion  primary  to  edema  bullosum  is  relieved  the  mucus  usually 
resumes  more  or  less  normal  conditions;  thus  its  importance  rests  on 
the  remedial  possibilities  of  the  causative  factor. 

7.  Edema  Trigoni  Simplex  or  Simple  Edema  of  the  Trigonum  has  been 
described  by  Pilcher  in  his  work  on  Practical  Cystoscopy.  The  writer 
has  seen  a  similar  condition  in  the  urethra  of  women.  Pilcher  describes 
the  condition  as  a  simple,  peculiar  edema  of  the  trigonum  seen  in  women 
more  than  in  men  as  the  expression  of  pressure  from  anteversions, 
retroversions  and  enlarged  cervix  of  the  uterus,  from  impaction  of 
feces,  from  any  ordinary  cause  of  chronic  congestion  of  the  trigonum, 
especially  the  conditions  leading  to  irritability  of  the  bladder  in  women. 
The  writer  himself  has  seen  it  in  connection  with  cystocele  with  its 
essential  hyperemia  and  dragging  on  the  trigonum.  Simple  edema  of 
the  trigonum  is  not  ordinarily  the  sign  of  previous  mfection  of  the 
bladder,  ureters  or  kidneys.  In  nature  it  seems  to  be  a  very  moderate 
degree  of  edema  bullosum. 


760  THE  BLADDER 

The  cystoscopic  picture  of  edema  tritioni  simplex  is  that  of  an  edema 
biillosmn  of  motlerate  degree,  sessile  in  its  origin  and  relatively  of  high 
congestion.  In  the  bladder  and  in  the  urethra  alike  it  is  readily  relieved 
by  gentle  swabbing  with  5  or  10  per  cent,  solutions  of  nitrate  of  silver, 
depending  (Mi  the  se^■erity. 

8.  Simple  Gysts  of  the  Vesical  Mucosa  are  of  little  pathological  mo- 
ment, solitary  and  single  or  reasonably  numerous  and  scattered.  They 
arise  as  the  early  or  late  sequels  of  inflannnation  and  as  simple  vesicles 
by  distention  or  retention.  Mucous  cry])ts  otherwise  normal  may  be 
unusually  i>rominent  and  appear  as  cysts  on  lateral  view,  or  may  be 
true  cysts  by  retention.  Others  of  these  simple  vesicles  are  due  to 
serous  effusion  and  in  this  resjject  resemble  single  blebs  of  edema 
bullosum,  and  when  very  numerous  and  closely  grou])e(l  virtually  pass 
over  into  that  lesion.  The  neck  and  trigonum  of  the  bladder  are  the 
conunonest  sites  of  their  apj^earance. 

Reactions  and  Lesions  of  the  Vesical  Muscularis  in  Disease  include 
temporary  and  ])ermanent  trabeculations  and  congenital  and  acquired 
diverticula. 

Trabeculations  have  been  fully  discussed  in  ])receding  ])ages.  It  is 
therefore  necessary  here  only  to  repeat  that  the  temporary  trabecula- 
tions are  functional  and  spasmodic,  and  that  the  permanent  degrees 
of  the  lesions  are  pathologic  and  organic,  and  that  by  continuance  of 
exciting  causes  the  functional  may  become  the  organic  condition. 

Congenital  diverticula  are  anatomical  abnormalities,  and  consist  in 
pouchings  and  offsets  from  the  cavity  of  the  bladder  as  secondary 
bladders  commimicating  with  the  primary  viscus  by  only  one  channel, 
as  a  rule.  Such  pouches  vary  in  size  and  location,  from  small  to  large 
diameters  and  from  zone  to  zone  of  the  bladder  wall,  excepting  the 
floor  where  they  are  practically  unknown. 

Cystoscopic  pictures  of  congenital  diverticula  of  the  bladder  depend 
on  whether  or  not  the  cystoscope  may  be  introduced  mto  them,  and 
whether  or  not  cystitis  as  a  whole  is  present,  or  diverticular  retention 
and  inflammation  have  occurred.  A  "  bull's-eye"  is  the  best  description 
for  the  opening  into  the  unilluminated  diverticulum  as  it  appears  in 
the  midst  of  a  more  or  less  healthy  bladder  wall,  varying  in  size,  black- 
ness and  flistinctness  largely  in  accordance  with  its  annexa.  The  depth 
of  the  diverticulum  may  be  tested  with  the  ureteral  catheter  and  in  a 
certain  sense  the  character  of  its  contents  known.  The  margins  of  the 
opening  are  sharp  or  ill  defined,  flat  or  elevated,  smooth  or  rough,  pale 
or  h^-peremic,  according  to  the  presence  or  absence  of  infection. 
Extrinsic  illumination,  that  is,  from  the  })ladder  cavity,  is  usually 
alone  possible,  because  our  cystoscopes  are  not  long  enough  to  pass 
into  such  a  pouch  after  suitable  dilatation  of  the  bladder  and  itself. 
But  some  information  may  be  gained  with  direct  field  instruments  and 
with  close  study  as  the  lamp  passes  the  margin,  giving  the  "shadow 
test;"  by  which  a  portion  of  the  cavity  is  illuminated  and  the  balance 
dark  from  the  shadow  cast  by  that  part  of  the  margin  which  is  directly 
opposite  the  lamp  and  hence  eclipses  the  cavity  behind  it.    Intrinsic 


CYSTITIS  761 

illumination  of  a  diverticulum  is  possible  only  when  conditions  pernnt 
such  exploration. 

The  contents  of  small  diverticula  are  usually  evacuated  with  the 
balance  of  the  bladder,  but  with  larger  examples  the  tendency  is 
toward  retention  and  decomposition  of  the  urine  so  that  mucus,  pus, 
precipitation  of  urinary  salts,  deep-seated  disease  of  the  walls  and  even 
lithiasis  occur — in  short,  all  the  conditions  in  miniature  of  prostatism 
and  cystitis.  Acquired  diverticula  of  the  bladder  are  pathological 
entities  always  associated  with  chronic  inflammation  and  obstruction, 
and  arising  from  two  factors:  Hypertrophy,  elevation  and  prominence 
of  certain  muscular  bands  in  the  effort  of  the  bladder  to  evacuate 
itself  through  the  obstruction;  and  atrophy,  depression  and  recession 
of  the  bladder  wall  between  them ;  so  that  gradually  these  pouches 
deepen  until  they  harbor  stones  of  various  size  and  show  the  pathology 
of  localized  retention  of  urine.  Acquired  diverticula  vary  in  number, 
diameter,  depth,  capacity  and  condition  of  their  wall  and  contents. 

Openings  of  the  Ureters,  Plica  Interureterica  and  Plicae  Uretericse. — 
These  anatomical  features  of  the  bladder  are  the  next  in  order  for 
description  as  to  their  pathological  details.  Inasmuch,  however,  as 
ureteral  examination,  exploration  and  treatment  are  properly  con- 
sidered under  sections  devoted  to  them  later  in  the  book,  it  seems  best 
to  leave  this  topic  as  a  proper  part  of  the  subject.  In  passing,  however, 
it  is  to  be  noted  that  the  observer  must  distinguish  the  normal  meatus 
in  its  muscular  activity,  rate  and  manner  of  urinary  evacuation  and 
annexa.  He  should  likewise  know  the  abnormal  meatus  as  to  its  con- 
genital anatomical  malformations  and  reduplications,  muscular  action, 
emission  of  pathological  urine  or  contents,  and  in  its  signs  of  disease 
in  the  annexa,  mucosa,  contractures,  traumatisms,  foreign  bodies,  neo- 
plasms and  special  pathological  processes  (particularly  tuberculosis). 

CYSTITIS. 

Definition. — Cystitis  is  defined  as  any  inflammation  of  the  bladder 
irrespective  of  cause,  course,  distribution  and  termination. 

Varieties. — Cystitis  is  recognized  (1)  as  to  occurrence — primary  by 
direct  focal  infection,  or  secondary  by  extension  in  continuity  or  con- 
tiguity or  by  transmission  through  the  blood  and  l;sTiiph  currents  of 
infection  situated  elsewhere  in  the  urogenital  tract;  (2)  as  to  course — 
acute,  subacute  and  chronic  and  remittent,  intermittent  and  relapsing ; 
(3)  as  to  cause — ^nonsuppurative,  suppurative,  neoplastic,  calcareous, 
tuberculous,  colon  bacillary,  etc.;  (4)  as  to  distribution — regional  or 
local,  patchy  or  disseminated  and  general  or  universal;  (5)  as  to  pro- 
ducts— purulent,  membranous,  ulcerative  and  necrotic. 

Regional  or  local  cystitis  may  affect  one  or  two  zones  of  the  cavity 
or  by  a  multiplication  of  the  pomts  affected  pass  over  into  the  dis- 
seminated type.  Generalized  cystitis  may  show  equal  intensity, 
diffused  everywhere  or  may  also  appear  as  more  severe  in  some  than 
in  other  zones.     The  ordinarv  signs  of  mucosal  mflammatiou  occur 


762 


THE  BLADDER 


in  cystitis,  tliversified  in  kind,  degree  and  site;  beirinning  in  ordinary 
hyperemia  and  passing  through  active  inHamniation  with  patches  of 
submucous  ecchymosis  and  hemorrliage,  with  exfoliation  and  erosion 
of  epithelium  of  different  severit>',  with  su])erficial  and  deej).  small  and 
extensi\e  ulceration  and  necrosis  and  finally  with  gangrene  in  extreme 
instances. 

Subjective  Symptoms.  —  Cystitis  varies  with  the  intensiiy  of  the 
inflannnation.  The  s>mptoms  are  discomfort  or  actual  pain  in  tlie 
general  bladder  /.one,  fre(|uency,  urgency  and  tenesnuis  of  micturition, 
pyuria  and  at  times  hematuria,  especially  terminal.  Thus  the  law  of 
all  mucous  membrane  inflammations  is  followed  in  that  irritation  of  the 
sensory  nerves  causes  the  i)ain  and  tliscomfort,  stimulation  of  tlie  sphial 


Fig.  212. — New  bladder  irrigator.  (Peterkin.')  From  above  down  are  connecting 
tube,  obturator,  double-current  catheter,  sheath  of  irrigator,  assembled  instrument 
ready  for  irrigation   and  finally  assembled  instrument  ready  for  introduction. 

reflex  induces  the  frequency,  urgency  and  tenesmus,  while  changes  in 
the  normal  secretion  and  damage  to  the  surface  of  the  mucosa  produce 
the  pus,  blood  and  descpiamation  of  e])ithelium. 

Acute  Cystitis. — Distribution  and  Extension. — Acute  cystitis  may  be 
focal  and  limited,  disseminate  hi  patches,  or  difluse  and  universal. 
Localized  and  circumscribed  cystitis  as  well  as  the  disseminate  and 
patchy  variety  show  a  mucosa  normal  or  nearly  normal  at  iminfected 
pomts.  The  several  areas  may  be  single  or  multii)le,  small  or  large, 
discrete  or  coalescent  and  finally  pass  into  the  diffuse  type  affecting 
the  bladder  as  a  whole.    The  original  foci  are  circumscribed  and  clearly 


»  Am.'  Jour.  Urol.,  1909,  xfii,  469. 


CYSTITIS  763 

outlined  against  their  annexa  of  normal  or  nearly  mucous  membrane. 
Diffuse  cystitis  if  watched  under  the  cystosc(>i)e  commonly  originates 
in  the  trigonum  and  adjacent  base  of  the  bladder  from  which  it  steadily 
extends  without  remission. 

Cystoscopic  picture  of  acute  cystitis  is  th(!  same  in  both  local  and 
diffuse  varieties  except  the  area  involved — in  other  words,  the  former 
is  a  minature  of  the  latter.  In  the  stage  of  invasion  or  congestion  there 
is  engorgement  of  the  individual  vessels  comm'on  to  the  normal  mucosa ; 
this  is  followed  by  the  appearance  of  vessels  usually  too  small  to  be 
seen  and  by  the  reddening  of  the  previously  normal  color.  Next  a 
diffuse  redness  without  separate  bloodvessels  occurs  with  ecchymoses 
beneath  the  mucous  membrane.  Simultaneously  the  surface  becomes 
dulled,  raised  and  irregular  and  the  secretion  changes  from  mucus  to 
an  exudate  of  mucopus  or  pus,  often  floating  in  the  distention  medium 
as  cotton-like  clouds  in  a  red  sky.  Exfoliation  of  epithelium  gives  a 
rough,  shaggy,  uneven  surface  and  the  transudation  of  serum  causes 
edema,  diffuse,  disseminate  or  localized,  in  few  or  many  blebs,  passing 
over  into  edema  bullosum.  Resolution  may  now  occur  by  a  reversal 
of  these  various  steps  until  the  terminal  congestion  is  reached,  or  the 
infection  pass  over  into  the  intense  degree,  involving  superficial 
ulceration  and  deep  necrosis,  both  of  various  extent  and  of  moth- 
eaten  or  mouse-gnawed  appearance.  The  exudate  now  becomes 
mucofibrinous  or  pyofibrinous  and  the  picture  becomes  darker  as  the 
deeper  layers  are  reached  and  show  thick,  tenacious,  adherent  detritus 
which  as  it  detaches  gravitates  to  the  dependent  parts  of  the  bladder 
and  forms  a  thick  layer  in  clumps  and  rolls,  like  mud  at  the  bottom 
of  a  puddle,  while  the  upper  portions  of  the  bladder  show  the  signs  of 
the  intense  disease  in  hyperemia,  exudate,  loss  of  tissue  and  the  like. 

Recovery  may  now  occur  leaving  behind  it  the  scars  of  the  ulcers 
and  necroses;  more  commonly,  however,  this  mucous  membrane  after 
so  severe  a  process  does  not  resolve  but  goes  on  to  chronic  inflammation, 
or  to  subacute  cystitis. 

To  the  foregoing  cystoscopic  features  should  be  added  the  bacterio- 
logic  elements,  namely,  the  organisms  causing  the  disease,  notably  the 
gonococcus.  Bacillus  coli,  Bacillus  typhosus  as  familiar  examples. 

Subacute  Cystitis. — Definition. — Subacute  vesical  inflammation  or 
cystitis  may  be  throughout  of  degrees  less  severe  than  the  acute  dis- 
ease, or  may  occur  as  the  stage  of  incomplete  resolution  of  the  latter 
more  or  less  indolent  and  mild  in  character.  Subacute  cystitis  may 
affect  a  single  zone  of  the  bladder  wall  or  several.  If  only  one  focus  is 
its  site  the  trigonum  is  most  commonly  involved.  If  several  foci  occur 
they  are  laid  down  in  spots,  patchy  or  streaky  in  character,  varying 
in  number,  size,  form  and  sites;  with  distinct  tendency  to  favor  the 
dependent  portions — namely,  thefloorand  trigonum,  upon  which  infect- 
ing detritus  must  lie  by  gravitation  from  all  other  points  of  the  bladder 
wall  until  evacuated. 

Cystoscopic  pictures  of  subacute  cystitis  reveal  the  aftected  areas 
as  having  dark  centers,  if  ulcerating,  and  white  centers  if  healed  or 


764  THE  BLADDER 

covered  with  tenacious  exudate.  Both  such  centers  are  surrounded  by 
a  halo  of  dull,  swollen,  hypereniic  mucosa  outside  which  is  another  halo 
of  engori^ed,  radiating  bloodvessels.  The  mucosa  as  a  whole  is  less 
ijlossy  and  more  red  than  normal.  If  the  base  of  the  bladder  is  chieily 
involved  the  mouths  of  the  ureters  are  raised,  puti'y  and  indistinctly 
outlined,  and  the  trii^onuni  as  a  whole  shows  chronic  congestion  and 
edema. 

In  brief,  sul)aeute  cystitis  is  clinically  a  disseminated,  chronic  c>'stitis. 

Chronic  Cystitis. — General  Features. — ( 'hronic  cystites  are  alike  in 
general  in  all  ft)rms,  to  which  are  a(Uled  ])articular  elements  in  the 
special  t^pes  hereinafter  described.    The  following  are  the  main  points: 

Distribution. — Chronic  cystitis  is  limited  chiefly  to  the  dejiendent 
anatomical  jxn-tions  of  the  bladder,  namely,  the  Hoor  and  the  trigomim 
on  which  the  inflammatory  debris  lies,  and  the  urethral  outlet  through 
which  it  drains — facts  which  invite  and  promote  infection  at  these 
pointy. 

The  cystoscopic  picture  in  chronic  cystitis  presents  the  bloodvessels 
less  distinct  than  usual  because  obscured  by  persistent  thickening  of 
the  mucous  membrane  and  loss  of  gloss  and  translucency.  The  color 
is  reddish  gray  instead  of  yellowish  red  from  the  same  thickening  and 
other  changes.  In  spots  where  the  vessels  show  through  the  red  color 
l)redominates.  In  the  up])er  quadrants  of  the  bladder  where  Nature's 
cleanshig  processes  are  unaffected  by  accumulation  on  the  surface 
there  may  be  nearly  normal  mucous  membrane  here  and  there.  The 
ureteral  outlets  share  the  same  disadvantage  as  the  rest  of  the  bladder 
floor  and  are  puffy  and  difficult  to  distinguish.  Chronic  cystitis  is 
therefore  a  process  which  shows  areas  of  recovery,  spots  of  remission 
and  patches  of  steady  low-grade  disease,  variously  correlated  with  the 
base  of  the  bladder  distinctly  most  affected.  The  secretion  is  no  longer 
strictly  such  but  an  exudate,  thick  and  clinging,  giving  to  the  surface  a 
smeared,  irregular,  broken  appearance.  If  the  chronic  catarrhal  passes 
into  chronic  productive  inflammation  the  small  round-cell  infiltration 
is  often  grouped  in  conglomerate  points,  difficult  to  distinguish  from 
early  carcinoma. 

Special  Forms. — Chronic  cystitis  for  description  is  subdivided  into 
chronic  cystitis  of  urethral  obstruction,  chronic  vesical  cervicitis  or 
chronic  trigonitis,  Knorr's  chronic  follicular  and  granular  cystitis, 
Knorr's  chronic  glandular  cystitis,  chronic  membranous  cystitis  or 
diphtheritic  cystitis,  hemorrhagic  cystitis,  chronic  gonococcal  cystitis, 
and  membranous  edema  of  the  trigone  of  Pilcher. 

The  following  are  their  featiu'es  in  brief: 

Chronic  Cystitis  of  Urethral  Obstruction. — Occurrence. — This  type  of  cys- 
titis is  far  more  common  in  males  than  in  females  and  is  due  to  stricture 
of  the  urethra,  prostatism  and  periurethral  neoplasms,  in  the  last  of 
which  the  cases  in  females  are  usually  classed.  The  features  of  stricture 
of  the  urethra  are  properly  treated  in  the  section  devoted  to  urethros- 
copy on  page  667,  and  likewise  those  of  hypertrophic  and  other 
lesions  of  the  prostate  are  more  fully  described  on  pages  943  and  946. 


CYSTITIS  765 

The  cystoscopic  picture  of  chronic  cystitis  of  urethral  o})struction 
is  much  the  same  in  all  cases,  beinji;  varied  only  by  elements  due  to  the 
particular  cause — as  given  in  the  following  list.  I  rethral  stricture  eases 
comprise  also  the  chronic  urethrocystitis  associated  with  the  obstruc- 
tion. Extravesical  and  extraurethral  tumor  cases  usually  emphasize 
circulatory  and  lymphatic  stasis.  Prostatic  cases  show  a  long  and 
varied  line  of  changes  in  the  roof,  sides  and  floor  of  the  vesical  neck, 
with  loss  of  its  marginate  relation  to  the  bladder  cavity;  irreguljirities 
in  the  floor  of  the  bladder  due  to  the  enlargement  of  the  gland;  infiltra- 
tion of  the  trigonum  due  to  the  chronic  congestion ;  and  finally  deforma- 
tion and  masking  of  the  ureteral  mouths  and  folds  through  changes 
in  their  annexa.  The  color  is  a  dirty  grayish-white  or  red,  the  blood- 
vessels are  hidden  by  the  thickening  in  the  epithelium,  edema  is  usually 
absent  through  the  chronicity  of  the  process,  elasticity  under  distention 
and  muscular  action  is  decreased  or  absent,  mucous  crypts  are  imper- 
ceptible as  a  rule  and  the  exudate  is  thick  and  mucopurulent.  The  most 
significant  feature  is  the  condition  of  the  muscularis.  Through  straining 
and  chronic  inflammation  a  large  number  of  muscular  bands  in  irregular 
arrangement  have  been  converted  into  permanent  trabeculse  through 
individual  hypertrophy,  some  being  very  large  and  others  much  smaller. 
The  spaces  between  these  bands  have  by  reversal  of  process  become 
atrophied,  weakened  and  even  herniated  so  as  to  comprise  permanent 
acquired  diverticula.  These  pouches  show  any  limit  of  diameter,  depth, 
distribution  and  degree  of  disease  in  their  cavity,  depending  chiefly 
on  their  capacity  to  empty  themselves.  Many  of  them  cannot  be 
illuminated  with  the  lamp  and  explored.  Not  infrequently  they  con- 
tain calculi  in  the  later  degree  of  the  cystitis.  The  more  severe  lesions 
are  usually  lowest  down  in  the  bladder  cavity  and  the  variety  is  so 
diverse  that  no  brief  description  is  adequate;  in  short,  any  ordinary 
chronic  inflammatory  process  may  be  present  at  one  or  more  points 
— catarrhal,  suppurative,  productive  or  necrotic,  and  progressing, 
stationary  or  resolving. 

Chronic  Trigonitis. — Definition. — Chronic  trigonitis  or  chronic  vesical 
cervicitis  is  a  chronic  cystitis  confined  to  the  outlet  of  the  bladder  and 
the  trigone.  It  is  often  the  terminal  stage  of  acute  diffuse  cystitis  or 
may  be  a  more  or  less  distinct  lesion  primary  in  itself. 

Cystoscopic  pictures  of  chronic  cystitis  portray  catarrhal,  suppura- 
tive and  productive  inflammation  of  the  trigone  and  cervix.  In  the 
catarrhal  form  there  are  congestion,  hyperemia,  edema  and  vesicula- 
tion  of  the  affected  region,  with  a  mucoid  discharge.  Suppuration 
increases  the  activity  of  all  these  processes  and  shows  pus  as  well  as 
mucus  and  detritus.  Productive  or  infiltrative  lesions  show  thickened 
mucosa,  more  numerous  and  dense  vesicles  and  even  tubercles  resem- 
bling those  of  tuberculosis  in  appearance,  but  not  in  structure.  The 
chief  complaints  of  the  patients  are  pollakiuria  and  dysuria  with 
pyuria,  especially  terminal. 

Hemorrhagic  Cystitis. — Definition. — Cystitis  is  called  hemorrhagic 
if  blood  appears  beneath  the  mucous  membrane  or  upon  its  surface 


766  THE  BLADDER 

and  is  evacuated,  freely  mixed  with  the  urim",  or  in  streaks  and  drops 
upon  the  phigs  of  mucus  and  pus,  or  in  the  more  or  less  pure  state 
at  the  end  of  micturition.  Almost  all  severe  cystitis  ])iisscs  through 
a  hemorrhajric  ])criod  of  Aaryinu;  intensity.  Cystoscopic  pictures 
of  hemorrhagic  cystitis  reveal  subnmcous  hemorrhage  in  })etechia', 
ecch\Tnoses,  patches  and  streaks  as  previously  described.  Hemor- 
rhagic cystitis  hardly  deserves  individual  classification  hut  sometimes 
the  blood  sj)ots  arc  a  very  distiuct  feature.  There  may  be  one,  few  or 
many,  very  large,  moderate  or  niimite  in  size  and  located  almost 
an\'where  in  the  bladder.  The  thicker  the  layer  of  blood  and  the 
older  the  process  the  darker  the  color,  so  that  sometimes  it  is  hard  to 
distinguish  ahnost  black  henn)rrhagic  s})ots  from  old  o])en  ulcers. 

Membranous  Cystitis.  —  Dcfiuiiion.  —  ^Membranous  or  di])htheritic 
cystitis  produces  a  false  membrane,  usually  on  the  floor  of  the  bladder 
about  the  trigonum,  through  the  deposit,  coagulation  and  adhesion  of 
the  products  of  chronic  suppurati^'e  inflammation  to  the  mucosa.  The 
lesion  has  nothing  to  do  with  the  Klebs-Loeffler  ba<-illus,  is  interesting 
and  unimi)ortant  except  for  the  ability  to  distinguish  it.  Detachment 
of  the  membrane  leaves  a  granular,  oozing  surface  beneath. 

Cystoscopic  pictures  of  membranous  cystitis  display  a  chronic  inflam- 
mation with  one  or  several  patches  of  membrane  present. 

Cystitis  FoUicularis  et  Granularis  (Knorr). — Dcfiniiion  and  Feaiures. — 
(iranular  and  follicular  cystitis  is  a  disseminate,  chronic,  productive 
inflammation  of  the  bladder  resulting  in  numerous  and  more  or  less 
closely  grouped  tubercles  not  unlike  tuberculous  foci.  Individual 
lesions  consist  of  small  romid-cell  masses  with  lymph  and  lymi)hocytes 
distributed  through  them  and  located  beneath  the  ei)ithelium. 

Cystoscopic  i)ictures  of  follicular  and  granular  cystitis  reveal  deep 
red  gromid  with  the  tubercles  scattered  over  it.  In  a  broad  and  general 
sense  the  lesion  looks  like  trachoma  of  the  eyelids. 

Glandular  Cystic  Cystitis. —  Dcfiniiion. — Knorr  terms  this  clu-onic 
lesion  cystitis  cystica  glandularis  and  Hokitansky  and  Klebs  herpes 
vesic3e  urinari-^.  It  is  a  cystic  degeneration  of  the  mucous  membrane 
during  chronic  trigonal  cystitis,  so  that  numerous  yellow  to  gray 
colloidal  cysts  are  produced.  In  another  sense  it  is  bullous  edema  of 
chronic  type  occurring  during  a  chronic  cystitis,  and  having  obvious 
cystoscopic  features. 

Acute  and  Chronic  Gonococcal  Cystitis. — Definition. — The  diplo- 
coccus  or  gonococcus  (Xeisser)  may  infect  the  bladder  with  acute  or 
chronic  inflammation.  It  is  comnn)jdy  distinguishable  from  other 
cystitis  only  by  bacteriological  in^'estigation,  which  should  be  carried 
out  in  every  case  as  routine.  The  chronic  lesion  usually  persists  in  the 
zone  first  infected — namely,  the  cervix  and  trigone  which  the  organism 
reaches  rarely  by  continuity,  as  it  does  not  often  i)ass  the  sphincter, 
but  commonly  by  contiguity  through  the  medium  of  instruments  and 
the  like.  The  acute  disease  is  so  marked  as  to  render  examination 
hazardous.  The  declining  stages  show  a  degree  of  congestion, 
hyperemia,  edema,  erosion  and  ecchymosis  which  characterize  gono- 


CYSTITIS 


767 


coccal  infection  in.  the  urethra  and  suggest  what  must  be  the  more 
marked  conditions  of  the  stages  of  increment.  (Chronic  gonococcal 
cystitis  shows  all  the  changes  of  other  persisting  cystitis  with  the  added 
presence  of  the  gonococcus  in  the  shreds  and  pus — variously  distributed 
spots  of  inflammation,  infiltration,  exfoliation  and  erosion  most  marked 
around  the  outlet  of  the  bladder. 

Tuberculous  Cystitis. — Definition. — Tuberculous  cystitis  is  a  sub- 
acute or  chronic  infection  of  the  bladder  with  the  bacillus  tuberculosis, 
occurring  exceptionally  as  a  primary  lesion  but  almost  universally  as 
an  involvement  secondary  to  tuberculosis  of  the  kidney.  It  is  most 
commonly  localized  in  one,  occasionally  disseminated  over  several 
zones  and  very  rarely  diffused  over  all  areas  of  the  bladder.  In  the 
last  form  there  is  always  an  associated  infection — germs  other  than  the 


Fig.  213. — Tuberculosis  of  the  bladder  and  ureter.  The  cystogram  shows  a  contrac- 
tured  bladder,  whose  degree  prevented  successful  cystoscopy  and  ureteral  catheteriza- 
tion. Fifty  per  cent,  argentide  solution  was  employed,  which  apparently  the  spasm  of 
the  bladder  forced  past  the  ureter  on  the  diseased  side,  giving  a  beautiful  ureterogram. 
A  second  but  futile  attempt  was  made,  in  the  hope  that  a  pyeloureterogram  would  result. 
(Author's  case.) 

Bacillus  tuberculosis — which  excites  the  generalization  of  the  cystitis 
and  gives  the  field  for  the  rapid  extension  of  the  tuberculosis. 

Focal  Symptoms. — Tuberculous  cystitis  has,  even  in  the  secondary 
cases,  not  renal  but  vesical  symptoms  and  of  intractable,  intense, 
progressive  degree.  They  are  chiefly  nocturnal  and  diurnal  pollaki- 
uria,  dysuria,  tenesmus,  stranguary,  pyuria  and  hematuria.  Two 
important  facts  stand  out  in  bold  relief  against  common  experience  in 
treating  other  forms  of  cystitis  compared  with  tuberculosis — namely, 
treatment  is  of  no  benefit  and  a  primary  focus  outside  the  urogenital 
tract  is  almost  impossible  to  find. 

For  the  purposes  of  clinical  convenience  therefore  it  is  proper  to 
consider  such  cases  as  primary  in  the  urogenital  apparatus,  although 
a  precedent  lesion  elsewhere  cannot  be  found.    The  vast  number  of 


768 


THE  BLADDER 


autopsy  fiiuling.s,  however,  sliowinjj;  healed  tuherculoiis  foei  in  the  hiiigs 
and  digestive  tracts,  make  it  likely  that  pathologically  many  of  these 
cases  arc  strictly  secondary. 

Urinalysis. — In  tuberculous  cystitis  tlu'  urine  is  highly  inij)ortant 
and  distinctive.  The  specific  gravity  is  rather  low,  tlie  reaction  acid, 
the  pus  prominent,  thickish,  tenacious  in  the  later,  rather  flaky  in  the 
earlier  stages,  and  smearing  the  surface  of  the  container  much  as  does 
sour  milk.  The  absence  of  other  pus-])roducing  organisms  in  the  urine 
is  a  peculiar  and  almost  pathognomonic  point.  Numerous  red  blood 
cells  and  a  few  drops  of  terminal  hematuria  are  also  notable.  Given 
these  features,  the  Bacillus  tuberculosis  should  always  be  looked  for  in 
smear,  culture  and  inoculation  tests  with  a  distinction  between  the 


Fig.  214. — .\clvanced  urojienital  tuberculosis.     Tj'pical  bullous  edema  of  the  trlKouuui 
and  deep  urethra  in  continuity;  diagnosis  repeated  by  urethroscopy.     (McCarthy.) 


bovine  and  human  varieties  when  possible.  The  guinea-pig  test, 
awaiting  the  death  of  the  animal  through  tuberculosis,  is  final.  \  more 
rapid  and  equally  reliable  method  is  to  inject  the  fluid  into  the  thigh 
and  after  three  or  four  days,  instead  of  as  many  or  more  weeks, 
examine  the  lymphatic  glands  of  the  groin  for  tuberculous  inflam- 
mation. 

Pathology. — Tuberculous  cystitis  follows  the  same  form  as  every- 
where else  in  the  body  and  shows  a  period  of  early  invasion  with  the 
formation  of  tubercles,  then  a  period  of  early  infiltration  with  superficial 
ulceration  of  the  tubercles  in  the  midst  of  the  chronic  mild  productive 
inflammation.  Next  is  the  stage  of  deep  infiltration  and  extension, 
followed  at  last  by  extensive  excavating  necrosis.  It  will  be  noted  that 
the  degree  of  infiltration  through  the  small  round  cell  production  and 


CYSTITIS 


769 


the  cutting  off  of  the  blood  supply  determines  the  depth  and  extent 
of  the  ulceration.  In  other  words,  the  process  duplicates  itself  in  form 
but  differs  in  degree.  This,  in  brief,  is  the  description  of  the  disease 
embodied  in  the  more  detailed  statements  of  authorities  like  Halle 
and  Motz. 

Cystoscopic  Pictures. — Tuberculous  cystitis  resembles  all  other  forms 
of  chronic  cystitis  with  the  added  features  of  the  tubercles  and  the 
bacilli.  Invasion  of  the  bladder  is  necessarily  very  difficult  and  painful 
except  in  the  earliest  stages,  as  the  bladder  is  irritable  and  intolerant 
in  tuberculosis  to  a  degree  often  disproportional  with  the  lesions  found. 
If  the  urine  is  clear  or  reasonably  so  it  is  often  well  to  attempt  the 
examination  with  it  as  the  medium  of  distention.  Inasmuch,  however, 
as  patients  with  tuberculous  bladders  seek  aid  on  account  of  hematuria 
or  pyuria  this  plan  cannot  be  adopted.  Local,  that  is,  vesical  anes- 
thetics, are  also  out  of  the  question  through  the  intolerance;  therefore 


Fig.  215 


Fig.  216 


Fig.  215. — Posterior  urethral  tuberculosis.  Right  tuberculous  epididymitis;  opera- 
tion not  advised;  benefitted  by  fresh  air  life;  diagnosis  corroborated  by  urethroscopy. 
(McCarthy.) 

Fig.  216. — Posterior  urethral  tuberculosis.  Renal  tuberculosis;  occluded  ureter;  nega- 
tive urine;  diagnosis  confirmed  by  urethroscopy.     (McCarthy.) 


most  cystoscopies  in  this  disease  require  a  general  anesthetic,  or  local 
anesthesia  by  spinal  or  sacral  administration.  The  operator  must 
frequently  content  himself  with  moderate  distention  and,  in  the  pres- 
ence of  copious  appearance  of  blood  and  pus,  with  in  and  out  irriga- 
tion through  ureteral  catheters  as  previously  described,  thus  clearing 
field  to  field  as  he  proceeds. 

The  appearance  of  the  mucosa  is  that  of  any  other  chronic  inflamma- 
tion with  distinct  tendency  toward  severity,  infiltration  and  thickening. 
The  tubercles  are  an  important  and  prominent  element  in  various 
stages  of  development,  so  that  the  older  examples  have  ulcerated  tops 
or  may  be  replaced  by  ulcers  in  the  midst  of  groups  of  tubercles  of 
earlier  growth.  The  fact  that  vesicle  lesions  are  secondary  to  renal 
lesions  determines  groups  of  tubercles  around  the  ureter  on  the  affected 
side.  The  disease  usually  spreads  slowly  so  that  only  a  small  area  may 
be  found  to  correspond  with  very  severe  suffering.  Forerunners  of  well- 
developed  miliary  tubercles  are  little  nodes  and  cysts  filled  with  gelati- 
49 


770  THE  BLADDER 

nous  .ind  grumous  matter  and  sometimes  suniiountcd  witli  granula- 
tions or  superficial  ulcers. 

Typical  miliary  tubercles  in  the  bladder  appear  toward  the  end  of  the 
early  invasion  as  small,  roundish,  pearlike  elevations,  scattered  more  or 
less  lawlessly  over  the  base,  or  slow  increase  in  size  and  prominence  and 
in  various  stages  of  development.  The  older  tubercles  are  less  white 
than  the  younger,  which  on  oblique  illumination  are  translucent  with 
a  yellowisli  center.  Increased  infiltration  loses  this  ai)pcarance  and 
induces  opacity  which  i)rccedes  ulceration  or  accompanies  it.  The 
tubercles  are  set  in  annexa  of  pale  rather  than  liyperemic  tissue  due 
to  the  infiltration  of  small  round  cells  and  tubercle  tissue.  Tubercles 
massed  close  together  may  merge  into  single  larger  deposits  of  tuber- 
culosis which  with  the  increasing  infiltration  break  down  into  ulcers 
of  considerable  size.  A  characteristic  of  the  disease  is  that  all  possible 
stages  and  a})pearances  are  detectable  with  care,  such  as:  tubercles  of 
small,  medium  or  large  size  with  all  tones  of  color  from  pearly  white 
to  ]:)iu'ulent  yellow,  with  all  degrees  from  translucency  to  opacity,  w'ith 
■\arious  superficial  or  deep  ulcerations  and  with  signs  of  steady  progress 
or  healing. 

Compound  tubercles  or  nodes  in  the  bladder  go  with  excess  of  inflam- 
mation around  their  sites  and  with  coalescence  into  a  common  area  or 
zone  of  tuberculous  infection  within  whose  boundaries  any  or  all  of  the 
foregoing  features  are  present. 

Necrotic  or  ulcerative  tuberculous  inflammation  of  the  bladder  adds 
to  all  the  foregoing  features  prominent,  productive  and  infiltrative 
changes  with  secondary  necrosis  and  ulcerations  which  may  be  super- 
ficial or  fleep.  The  older  the  process  the  more  pronounced  the  thicken- 
ing and  the  excavation.  Such  are  seen  where  the  infection  is  commonly 
oldest,  namely,  around  the  mouths  of  the  ureters  and  the  folds  over  and 
between  them.  The  characteristic  tuberculous  ulcer  is  as  follows:  The 
infiltration  produces  elevation  of  the  ulcer  as  a  whole  even  after  the 
tubercle  from  which  it  originated  may  have  been  completely  destroyed. 
The  outline  is  utterly  lawless  and  irregular,  the  edges  raised,  under- 
mined and  thickened  and  the  base  mouse-eaten,  irregular,  indolent 
and  necrotic.  As  the  urine  is  acid  there  is  very  rarely  any  phosphatic 
or  other  crystalline  deposit  upon  the  ulcer.  Some  ulcers  are  healed 
lea^'ing  dense  scars,  others  in  the  process  of  healing  and  still  others 
continuing  their  destruction — in  severe  degrees  of  tuberculosis  of  the 
bladder. 

Differential  Diagnosis. — Just  as  the  cystoscopic  features  vary  so  the 
early  ])rominent  symptoms  of  vesical  tuberculosis  dift'er,  and  from  the 
pathological  changes  one  can  very  easily  see  w^hy  some  cases  at  first 
show  an  early,  mild,  subacute  course  with  little  urinary  change,  others 
with  extension  and  development  are  more  severe  with  pyuria  as  a 
prominent  feature,  and  still  others  with  precocious  ulceration  show 
hemorrhage  as  the  prevailing  sign. 

The  predominant  feature  of  tuberculosis  of  the  bladder  is  intracta- 
bility to  all  ordinary  treatment  and  should  therefore  always  come 
into  mind  when  such  treatment  fails  in  any  case. 


CYSTITIS  111 

Idiopathic,  subacute  cystitis  during?  or  before  midlife,  unexplained 
by  history  or  examination  for  primary  focus,  and  unrelieved  i)y  treat- 
ment suf^gests  four  lesions:  calculus,  solitary  vesical  ulcer,  new  growth 
and  tuberculosis.  The  cystoscoyjc  will  distinguish  each  from  the  other 
three  with  ease,  as  a  rule,  combined  with  its  adjuvants  radiography, 
urinalysis,  bacteriologic  smear,  culture  and  inoculation.  Tuberculin 
treatment  may  benefit  or  reaction  to  it  may  aid  in  the  diagnosis. 
Von  Pirquet's  test  is  not  final  but  may  be  helpful  and  suggestive. 

Idiopathic,  severe  cystitis  at  any  period  of  life  without  definite 
foundation  in  history  or  examination,  and  without  benefit  from  good 
management,  and  with  pyuria,  having  the  distinctive  qualities  of  the 
urine  of  tuberculosis  previously  described,  emphatically  implies  infec- 
tion with  the  bacillus.  The  cystoscope  will  aid  in  showing  numerous 
and  diverse  lesions.  Idiopathic  hematuria  in  the  midst  of  moderate 
or  seyere  cystitis  frequently  suggests  thorough  investigation  for  tuber- 
culosis of  the  urinary  tract,  especially  kidneys  and  bladder.  Most 
commonly  the  hemorrhage  is  found  to  proceed  from  the  kidney,  occa- 
sionally from  the  bladder,  through  erosion  of  a  necrotic  tubercle  into  a 
bloodvessel  of  some  size.  The  cystoscope  will,  with  or  without  in  and 
out  irrigation,  permit  one  to  recognize  the  presence  of  neoplasm,  oozing 
from  the  ureter  or  bleeding  from  a  tubercle  as  the  source  of  the  blood: 

The  operative  cystoscope  is  of  signal  service  in  these  differential 
diagnoses  in  that  with  the  biting  forceps  a  whole  tubercle  or  other  small 
lesion  may  be  removed  and  histologically  studied.  Such  a  procedure 
simplifies  the  diagnosis  enormously  and  with  proper  judgment  and 
conservatism  is  the  method  of  first  choice. 

Treatment. — The  measures  in  tuberculous  cystitis  vary  m  the  mild, 
severe  and  intense  cases.  A  diagnosis  once  established  suggests  tuber- 
culosis of  the  kidney  of  either  or  both  sides.  Some  mild  cases  may  be 
benefited  by  tuberculous  bacterins,  especially  the  bacillus  emulsion 
in  orderly,  regular  and  ascending  dosage  every  three  days,  after  the 
method  of  Trudeau. 

Advanced  cases  are  more  serious,  and  with  both  kidneys  involved, 
hopeless.  With  one  kidney  involved  a  nephrectomy  may  be  done  with 
great  caution  not  to  infect  the  wound  with  tuberculosis  and  not  to 
leave  much  of  the^ureter  behind.  The  removal  of  the  main  foci  above 
permits  the  bladder  to  heal  spontaneously  as  a  rule. 

Solitary  tuberculous  vesical  foci  indicate  destruction  of  the  tubercles 
and  the  ulcers,  which  may  be  carried  out  with  the  operating  cysto- 
scope and  the  Oudin  or  d'Arsonval  current,  various  chemical  caustics, 
rongeur  forceps,  with  cauterization  of  the  base  left  behind.  Generalized 
cystitis  is  benefited  with  emulsion  of  iodoform  in  glycerm. 

Extensive  destructive  disease  of  the  bladder  may  be  benefited  by 
excision  when  the  zone  is  favorably  placed  for  it.  But  such  an  operation 
is  fraught  with  the  danger  of  infecting  the  wound  and  even  the  system 
at  large.  Suprapubic  drainage  to  rest  the  bladder  from  spasm  is  often 
a  last  and  only  resort  and  soon  leads  to  extension  of  the  disease  along 
the  path  of  drainage.  INIorphinism  for  the  relief  of  pain  is  the  last 
stage  for  these  unfortunate  victims. 


n2  '  THE  BLADDER 

In  coinhination  witli  tin*  t'oivi^oiiii;  nianaijcnuMit  witli  haetoriiis  and 
varions  snrgical  proceihircs,  all  the  modern  details  of  dietetic  and 
hygienic  treatments  should  be  added.  When  possible,  climatic  change 
should  be  secured,  which  is  at  least  always  feasible  to  the  degree  of 
plenty  of  fresh  air  in  the  living  and  sleeping  quarters.  In  other  words, 
as  in  tuberculosis  elsewhere  in  the  body,  the  (lisease  should  be  attacked 
not  only  by  local  attention  but  also  l)y  building  up  tlie  resistance  of 
the  i)atient's  system  in  every  practicable  way. 

Cystitis  Senilis  Feminanim. — Under  this  heachng  Charlton^  reports 
about  .")()  obsiTN  atioiis  dui-ing  fifteen  years  of  practice.  The  causes 
seem  to  be  advanced  life,  frecpient  childbearing,  lowered  vitality  and 
exposure.  It  has  no  relation  with  sexual  life  or  urinary  obstruction  as 
in  prostatics.  Its  onset  is  gradual,  long  after  menopause,  usually  in 
multi])ara'  and  is  characterized  by  ardor,  fre(|uency  and  tenesmus. 
Only  1  case  was  in  an  unmarried  woman.  The  course  is  chronic  through 
the  rest  of  life,  varying  in  distress  and  comfort.  Exacerbations  for 
weeks,  severe,  disturbing  and  depreciating  may  be  followed  by  months 
of  comparative  relief.  The  termination  is  without  recovery  as  the 
disease  is  atrophy.  Charlton  has  had  Jio  autopsies,  lie  noted  the 
urine  as  clouded  with  mucus  and  pus  but  rarely  bloody  and  never  thick 
or  ropy  with  strings  of  pus  and  mucus.  No  specific  bacterial  infec- 
tion has  been  determined,  but  the  Staphylococcus  pyogenes  is  common 
with  the  Bacillus  coli  and  its  allies.  An  undetermined  chain  bacillus 
is  found.  The  smegma  liacillus  is  always  a  contamination,  if  ])resent. 
The  Bacillus  of  tuberculosis  was  never  found.  Wassermann's  blood 
test  has  been  negative  in  cases  seen  since  the  introduction  of  this  test. 
Cystoscopy  reveals  a  bullous  edema  sharply  outlined  in  healthy  mucosa 
similar  to  herpes  zoster  in  the  skin.  Later  pigmentation  occurs. 
Vaginoscopy  and  proctoscopy  both  re\Tal  allied  lesions  in  their  respec- 
tive canals.  Senile  vaginitis  is  familiar  and  is  usually  regarded  as 
atrophy  in  the  submucous  tissue  followed  by  further  atrophy  in  the 
epitheliinn  and  then  by  erosions  and  ulcers.  The  advent  of  bacteria 
augments  these  briefly  outlined  conditions.  The  picture  of  the  bladder 
in  these  duplicates  that  in  the  atroj^hic  vagina  after  such  secondary 
infection.  The  rectum,  according  to  Charlton,  variously  shows  multiple 
punctate  erosions  and  large  distinct  punched  out  areas.  It  shows  deeper 
injection  than  the  Idadder  and  larger  areas  of  degeneration,  ])erhaps 
from  fecal  irritation  and  traumatism.  Urethroscopy  was  done  in  two 
cases  and  showed  analogous  conditions  in  the  urethra.  Charlton 
regards  the  disease  as  homologous  and  analogous  with  senile  bronchitis, 
conjunctivitis  and  nasopharyngitis,  but  it  does  not  occur  in  the  male 
in  his  studies.  The  only  treatment  is  hygiene,  support,  argyrol  instil- 
lations, alkaline  douches  for  the  vagina  and  rectum  and  five  to  ten 
drops  of  pure  guaiacol  three  times  a  day  internally  or  similar  mild 
measures.     Nothing  surgical  may  be  attempted. 

'  Tr.  \m.  Urol.  Assn.,  1916,  x,  40. 


PLATE  XI 


Case    1.     Presenting    vesicixlopapular    elevations    typically     observed    during 
acute  exacerbations — associated  diffuse  inflammation. 


■V 


Case  2.  Apparently  pigmented,  pateiiy,  eeehymotic  appearance  seen 
during  interval  period.  This  ease  has  previously  sho^vn  the  lesion  seen 
in   Fig.   1. 

Cystitis  Senilis  Feminaruin.     (Cliarlton.i) 
1  Trans.  Amer.  Urol.  Asso.,  vol.  x,  1916. 


ULCERATION  AND  NEOPLASM  OF  THE  BLADDER  773 

ULCERATION  OF  THE  BLADDER  AND  NEOPLASM  OF  THE 

BLADDER. 

General  Considerations. — Ulcer  and  neoplasm  of  iIk;  bladder  are 
discussed  together  in  this  section  on  the  ground  that  the  largest 
number  of  ulcers  represent  the  early  necrotic  stage  of  cancer  and  that 
in  a  certain  sense  the  thickening  and  infiltration  in  the  annexa  of  other 
ulcers  make  them  also  on  the  borderline  of  new  growths.  It  is  well 
known  that  everywhere  in  the  body  a  chronic  ulcer  originally  benign 
may  subsequently  become  malign  in  its  tendencies,  which  is  only 
another  reason  for  the  association  of  these  two  suV^jects. 

Ulceration  of  the  Bladder. — Definition. — ^Vesical  ulcer  or  localized 
necrotic  inflammation  "may  be  defined  as  a  focal  death  of  the  mucosa, 
usually  superficial  but  occasionally  deepened  to  the  muscularis,  of 
highly  variable  size  from  minute  to  large  limits,  of  firm  to  dense  infil- 
tration and  thickening,  of  moderate  to  unmistakable  elevation  above 
its  annexa,  of  usually  slow  but  occasionally  rapid  progress  and  of  almost 
invariably  distinctive  hyperemic  surroundings.  As  a  rule  the  more 
marked  these  features  are  the  greater  the  suggestion  of  cancerous 
malignancy. 

Varieties. — Varieties  of  vesical  ulcer  other  than  the  focal  necrotic 
inflammation  already  described  in  severe  cystitis  and  in  tuberculosis 
of  the  bladder,  comprise  ulcers  due  to  injury,  to  specific  organisms  like 
the  Bacillus  typhosus,  to  unknown  cause  as  the  "solitary  ulcer"  of 
Fen  wick  and  finally  to  cancer  itself. 

Cystoscopic  pictures  of  vesical  ulcer  vary  greatly  as  was  pointed 
out  by  Fen  wick  in  his  work  on  "  Clinical  Cystoscopy."  The  same  rules 
of  observation  hold  good  in  the  study  of  any  vesical  lesion  and  cover 
the  following  main  points  resting  on  the  degree  of  distention  of  the 
bladder.  Under  normal  or  full  distention  without  pain  the  lesion  looks 
like  a  loss  of  substance  from  a  more  or  less  flat  concave  surface  and 
shows  little  or  no  protrusion  above  the  surface.  If  now  the  degree  of 
distention  is  decreased  so  that  the  previously  smooth  wall  of  the  bladder 
relaxes  into  folds  the  ulcer  deepens,  decreases  in  apparent  size  and 
increases  in  elevation.  If  with  the  eye  still  on  the  lesion  the  distention 
is  renewed  and  carried  beyond  the  normal  to  the  painful  limit  the 
thickish  margins  of  the  ulcer  may  crack  even  into  the  base  of  the  sore 
with  consequent  smart  hemorrhage.  If  stiU  more  fluid  is  added  or 
if  the  ulcer  is  unusually  friable  the  tears  instead  of  being  small  and 
superficial  become  large  and  involve  even  the  muscular  coat,  so  that 
extravasation  of  the  urine  is  possible. 

Traumatic  Ulcer.- — Traumatic  ulcer  results  from  injury  by  chemical, 
mechanical,  electrical  and  thermal  means.  Such  damage  arises  from 
concentrated  antiseptics,  unskilful  use  of  instruments,  irrigating  fluids 
of  too  high  temperature  and  errors  in  the  application  of  electric  cur- 
rents in  modern  therapy  of  the  bladder  tlirough  operation  cystoscopes. 
The  cystoscopic  lamp  may  through  carelessness  cause  burns  and  trau- 
matic ulcer. 


774  THE  BLADDER 

The  cystoscopic  picture  of  traumatic  vesical  ulcer  is  tliat  of  similar 
lesion  in  any  other  nuicous  membrane,  namely,  a  firm  to  thickish, 
irregular,  shallow  sore  with  slightly  elevated  but  punched  rather  than 
undermined  edges  and  a  granulating  base,  quite  smooth  and  of  pale 
yellowish-red  color.  A  halo  of  active  hNperemia  is  next  to  the  ulcer 
and  jjrominent  bloodvessels  are  everywhere  abundant. 

Typhoid  Ulceration. — Ty})hoid  ulceration  is  rare,  always  occurs  with 
a  present  or  recent  history  of  enteric  fever,  complicated  with  pro- 
nounced cystitis.  The  appearance  of  the  lesion  is  like  that  of  typhoid 
ulcer  in  the  intestine.  Diagnosis  is  made  by  the  history,  the  presence 
of  the  Bacillus  typhosus  in  the  urine  and  the  cliaracter  of  the  Widal 
reaction  in  tlie  l)lood. 

Solitary  Vesical  Ulcer  of  Fenwick. — This  ulcer  is  clinically  a  chronic, 
indolent,  focal  necrosis  closely  resembling  a  tuberculous  ulcer  and  at 
times  impossible  to  distinguish  from  it  excepting  through  the  following 


Fig.  217. — Cystoscopic  ulcer  or  burn.    The  slough  is  apparent  in  a  Ixisis  of  inflammation 
and  edema.    The  enlarged  bloodvessels  are  significant.     (Knorr.') 

differential  points:  the  detection  of  the  Bacillus  tuberculosis  or  tubercle 
tissue.  The  urine  will  sooner  or  later  contain  the  organism  for  mor- 
phological inspection,  and  the  inoculation  of  guinea-pigs  either  into 
the  peritoneal  cavity  for  death  in  six  to  eight  weeks  or  into  the  thigh 
for  tuberculous  lymphadenopathy  in  one  to  two  weeks  will  demon- 
strate the  identity  of  the  organism  found.  By  a  still  more  modern 
method  a  small  deep  piece  from  the  margin  of  the  ulcer  may  through 
the  operation  cystoscope  be  removed,  sectioned  and  shown  to  contain 
tubercle  tissue  if  not  the  organisms  themselves.  These  solitary  ulcers 
are  also  distinguished  from  tuberculous  necrosis  and  from  cancerous 
ulceration  by  their  somewhat  greater  and  more  rapid  tendency  to  heal 
with  resultant  cicatrization,  contracture,  deformation  and  irritability 
of  the  bladder,  chiefly  through  the  chronic  cystitis  which  may  never 
get  well.    Fenwick  compares  solitary  ulcer  of  the  gastric  and  vesical 

•  Die  Cystoskopie  und  Urethroskopie  beini  Weilx;,  1908,  p.  214. 


ULCERATION  AND  NEOPLASM  OF  THE  BLADDER 


775 


mucosae  along  the  following  general  lines:  Each  is  near  an  orifice  of 
its  respective  viscus.  The  bladder  lesion  is  near  a  ureter  and  the 
stomach  lesion  close  to  the  pylorus.  Each  ulcer  occurs,  as  a  rule,  singly 
either  in  the  mucosa  itself  or  in  a  lymphatic  node.  Each  ulcer  has  a 
distinct  tendency  by  extension  to  erode  into  bloodvessels  and  cause 
bleeding  as  a  prominent  recurrent  or  persistent  symptom,  lioth 
gastric  and  vesical  ulcers  if  healed  leave  deep  infiltrating  scars  which 
soon  harden,  contract  and  deform  their  immediate  annexa,  which 
becomes  especially  important  if  stenosis  of  the  pylorus  or  ureter  ensues. 
Both  these  classes  of  ulcer  commonly  appear  in  midlife  or  earlier  and 
seem  to  be  without  well  proved,  definite  cause.  The  bladders  of  men 
and  the  stomachs  of  women  suffer  most  frequently.  The  normal  con- 
tents of  both  viscera  are  changed,  that  of  the  stomach  being  hyperacid 
and  that  of  the  bladder  alkaline. 


Fig.  218. — Tumors  of  the  bladder.     Adherent  blood  clot,  simulating  infiltrated  tumor. 
(Marion,  Heitz-Boyer,  Germain. i) 

The  cystoscopic  picture  of  solitary  ulcer  of  the  bladder  shows  a 
lesion  from  2  to  3  cm.  across,  not  very  deep  or  even  shallow,  irregular, 
raised,  infiltrated  but  not  undermined  edges  and  an  eroded,  slough- 
covered  base.  Cystitis  is  always  present,  the  urine  is  usually  alkaline 
and  a  deposit  of  phosphates  may  be  present  on  the  sore. 

The  symptoms  of  vesical  ulcer  are  dysuria,  pollakiuria  and  hema- 
turia associated  with  pyuria  and  phosphaturia. 

Varieties  of  cancerous  ulcer  may  be  recognized  as  four:  (1)  cancerous 
ulcer  or  necrosis;  (2)  superficial  cancerous  ulcer;  (3)  indurated  can- 
cerous node;  and  (4)  fimbriated  or  fungoid  cancer. 

Cancerous  Ulcer  or  Necrosis. — Cancerous  ulcer  and  necrosis  give  the 
following  symptoms  by  stages:  During  the  period  of  invasion  and 
moderate  involvement  irritability  and  pollakiuria  predominate.  As 
soon  as  the  neoplasm  has  reached  the  stage  of  necrosis  suppuration 
and  infection  intervene.  Pain  which  previously  was  indefinite  is  at 
this  moment  positive,  lancinating  and  suprapubic  or  referred  to  the 
urethral  meatus.  Hematuria  sooner  or  later  appears  with  extension 
of  the  ulcer  into  the  level  of  the  larger  bloodvessels  and  the  necrosis 


'  Loc.  cit. 


776  THE  BLADDER 

produces  shreds  of  sloughing  material.  A  peculiar  odor  of  rotten  meat 
shown  by  the  urine  is  proof  i)ositive  of  cancer.  Instead  of  active  hema- 
turia tlie  slugs  of  nuicus  and  fragments  of  tissue  cast  oH"  may  be  spotted 
or  streaked  witii  clots.  As  soon  as  the  new  gro\\'th  possesses  size  and 
weight  it  acts  as  a  foreign  body  and  produces  sudden  pain  and  tenesmus 
at  the  end  of  urination  as  do  likewise  the  plugs  of  nuicus  and  tissue 
cast  oti'. 

Sujn'rficial  cancerous  uJccration  is  pathologically  an  e])itheli(nna 
affecting  principally  the  base  and  the  trigonum,  growing  at  first  slowly, 
later  more  rapidly,  beginning  and  extending  superficially  in  its  early 
history  with  infiltration  and  dee])  fixation  later.  The  edges  are  thick, 
raised  and  everted  in  a  higher  degree  at  some  points  than  others.  Like 
epithelioma  of  the  lip,  for  example,  its  onset  is  either  as  a  white,  dense 
spot  in  the  mucosa  with  bloodvessels  distinctly  running  into  it,  or  as  a 
nodular  deposit.  In  a  short  time,  as  a  rule,  both  break  down  in  the 
center  as  open  ulcers.         • 

Indurated,  cancerous  nodide  affects  the  base  and  trigonum  as  does 
epithelioma  but  differs  from  it  in  being  a  rounded,  raised  tumor  or 
tubercle  of  unmistakably  rapid  growth,  of  deep  involvement  of  the 
annexa  and  underlying  parts  and  of  rather  early  fixation.  When  its 
ulcerative  stage  appears  the  focal  necrosis  is  deep,  thick,  infiltrated, 
tubercular  and  nodular,  having  uneven,  prominent,  everted,  thick  and 
hard  edges.  Later  a  mucopurulent  or  hemorrhagic  sloughing  appears 
with  shreds,  strings  and  masses  cast  off  and  also  a  very  foul  odor  of 
decaying  flesh  to  the  urine.  Intense  cystitis,  which  casts  off"  coagula  of 
blood,  pus,  mucus  and  necrosed  shreds,  always  supervenes. 

The  symptoms  of  nodular,  cancerous  ulceration  are  in  the  early 
stages  pain  and  irritability  of  the  bladder  without  cystitis,  while 
during  the  stage  of  necrosis  the  pain  is  increased  and  fixed  and  there 
are  present  pollakiuria,  dysuria,  pyuria,  tenesmus  wdth  terminal 
hematuria,  sloughs  acting  as  foreign  bodies  and  in  short  every  possible 
condition  of  profound  and  severe  chronic  cystitis. 

Nodular  cancerous  ulcer  may  pass  rapidly  into  the  fungoid  type. 

Fungoid  cancerous  ulceration  repeats  all  the  foregoing  features  wath 
the  addition  that  the  edges  and  sometimes  the  body  of  the  growth 
erupt  into  excrescences  of  the  general  fungoid  appearance  not  unlike 
papillomata  grouped  around  an  open  sore,  or  the  growth  may  be 
papillary  at  the  outset  and  later  necrose  at  one  or  many  points. 

Neoplasms  of  the  Bladder. — Variations  in  Symptoms. — Variations  in 
sjTiiptoms  range  between  "silent"  growths  which  for  a  long  period  of 
their  early  history  produce  a  few  insignificant  symptoms,  and  "  rampant" 
growths  which  early,  late  and  throughout  their  course  show  several  or 
many  usually  severe  sjonptoms.  Thus  it  is  that  routine  cystoscopy 
carried  out  for  the  sake  of  putting  the  touch  of  finish  on  urogenital 
diagnosis  often  discovers  new  growths  of  the  bladder  which  had  pre- 
viously never  manifested  their  presence  by  either  subjective  or  objective 
sjTuptoms. 


ULCERATION  AND  NEOPLASM  OF  TIIM  li LADDER  111 

Diagnosis. — The  diagnosis  may  be  reached  on  tjie  old  gwieral  jjrin- 
ciples  by  which  objective  vesical  symptoms  were  formerly  judged,  not 
infrequently,  however,  with  misleading  or  i)ositively  erroneous  results. 
In  cases  of  doubt  exjjloratory  cystotomy  was  the  last  resort,  but  not 
uncommonly  failed  to  distinguish  vesical  from  renal  hematuresis.  This 
operation  is  today  almost  obsolete. 

Cystoscojjy . — Cystoscopy  in  neoplasms  is  the  new  and  in  many 
respects  the  final  advance  in  objective  diagnosis,  as  it  })riiigs  th(;  obser- 
vation of  the  investigator  directly  to  the  lesions  and  n^quires  only  the 
proper  experience  and  interpretation  to  become  absolute.  It  is  not 
without  many  difficulties,  chiefly  due  to  infection,  hypertrophy,  irri- 
tability and  intolerance  of  the  bladder,  bleeding  and  mechanical  ob- 
struction by  growth.  Removal  of  these  obstacles  is  commonly  })rought 
about  by  deliberation,  patience,  styptics  and  anesthetics,  locally  to  the 
urethra  and  bladder  or  to  the  entire  urogenital  nerve  supply  through 
spinal  and  sacral  administration. 

The  cystoscopic  diagnosis  of  new  growth  is  scarcely  complete  unless 
the  number,  site,  size,  attachment,  infiltration,  appearance  and  general 
condition  of  each  neoplasm  is  recognized  and  recorded.  The  best 
method  of  record  is  that  of  plotting  the  offending  growth  or  growths 
on  an  outline  anatomical  chart. 

Examination  and  record  of  the  neoplasms  as  complete  as  this  will 
ordinarily  mdicate  also  the  course  of  treatment  such  as  intravesical 
cauterization  with  the  Oudin  and  d'Arsonval  currents  or  intra- 
abdominal removal  extraperitoneally  or  intraperitoneally  by  partial 
or  complete  resection  of  the  bladder. 

Preparation  for  cystoscopy  implies  systemic  and  local  measures. 
The  systemic  means  are  catharsis,  bodily  and  nervous  repose  in  bed 
for  twenty-four  hours,  vesical  repose  by  light  diet  and  cleansing  with 
urinary  antiseptics.  All  these  are  not  always  possible  but  should  be 
borne  in  mind  and  applied  when  circumstances  permit. 

Local  preparation  includes  irrigation  of  the  bladder  with  bland, 
rather  hot,  fluids,  which  are  solvent  of  pus  and  blood  at  first  and  later 
mildly  styptic  and  finally  anesthetic.  For  this  purpose  no  anesthetic 
is  better  than  2  per  cent,  alypin  retained  fifteen  minutes.  Water  is 
essentially  the  best  medium  but  if  the  bleeding  is  so  rapid  as  to  cloud 
it  immediately  air  and  oxygen  may  be  substituted.  A  very  valuable 
preliminary  is  to  insert  the  instrument  mto  the  distended  viscus  whose 
separated  walls  usually  carry  the  neoplasm  away  from  contact  with  the 
instrument  which  avoids  bleeding.  Obstacles  to  cystoscopy  comprise 
those  proceeding  from  the  bladder  as  a  viscus  and  those  from  the  new 
growth  as  a  foreign  body.  The  bladder  as  a  viscus  is  sooner  or  later 
infected,  irritable,  incontinent  and  hypertrophied  all  in  various  degrees. 
These  symptoms  render  it  most  difficult  if  not  impossible  to  carry  out 
irrigation,  distention  and,  of  course,  mstrumentation.  The  cystitis 
may  produce  a  real  incontinence  from  the  presence  of  pus  and  detritus 
on  the  bladder  floor  and  from  changes  in  the  urme  by  which  precipi- 
tation is  determined. 


77S  THE  BLADDER 

The  tumor  mass  acts  as  a  foreign  body  ami  iiuliices  many  of  the  fore- 
going obstacles  from  the  bladder  and  may  itself  become  a  barrier  into 
which  the  lamp  may  be  buried  during  the  introduction  or  it  may 
actually  obstruct  the  introduction  of  the  cystoseoi)e.  I'sually  such 
tumors  of  the  bladder  may  be  recognized  by  bimanual  examination  in 
both  sexes. 

Varieties. — Vesical  neoplasms  include  (1)  among  the  benign  forms 
fibrous  i)ai)illoma,  A'illous  ])ai)ill()ma,  myonui  and  iibroma  and  (2) 
among  the  malign  forms  carcuu)ma  of  papillary,  fibrous,  infiltrating 
and  colloid  types  and  sarcoma  of  infiltrating  and  nonmfiltrating  types 
and  ()))  among  transitional  forms  adenoma  and  myxoma. 

Benign  Fibrous  Papillomata  are  as  a  rule  solitary,  situate  in  any  ])art 
of  the  bladder,  from  pea-size  to  egg-size  (0.5  to  (3  cm.  hi  diameter), 
nodular  in  surface,  irregularly  spherical  hi  form,  pedunculated  in  attach- 
ment, fibroid  m  constitution,  benign  in  course  and  usually  "silent"  in 
SNinptoms  so  that  they  are  incidentally  disco\cred  during  cystoscopy 
for  other  purposes;  Their  mobility  on  their  long  pedicles  permits  them 
to  wave  about  m  the  contents  of  the  bladder  so  as  to  accommodate 
themselves  to  its  muscular  action,  ordinarily  without  symptoms.  They 
thus  strongly  resemble  uterine  fibroids.  Their  vascularity  is  not  very 
great  and  their  significance  as  a  rule  is  unimportant. 

Benign  Villous  Papillomata  are  like  the  benign  fibrous  form,  solitary 
in  occurrence,  situated  usually  around  the  ureter,  of  highly  variable  size 
with  tendency  to  gro^^'th  of  fimbriated  instead  of  nodular  surface  and 
irregular  mstead  of  spherical  form,  sessile  rather  than  pedunculated, 
complex  rather  than  simply  fibroid  in  constitution,  highly  vascular 
and  usually  hemorrhagic  with  distinct  tendencies  toward  malignancy, 
multiplication  and  dissemination  over  the  trigone,  ureteric  folds  and 
posterior  fundus ;  m  other  words,  the  floor  as  a  whole.  I '  sually  they  are 
discrete  but  may  be  massed  and  packed  together  into  a  cauliflower-like 
mass.  If  pedunculated  the  mass  as  a  whole,  like  its  villi,  moves  about  in 
the  fluid  medimn,  but  if  sessile  only  the  fimbriae  wave  in  and  out  the 
field.  These  villi  make  the  mass  look  like  a  tuft  of  seaweed,  may  be 
long  or  short,  few  or  many,  delicate  or  coarse,  vascular  or  pale  and  hence 
reddish-yellow  or  whitish  in  color.  These  papillomata  are  not  "silent" 
but  soon  cause  sjmptoms,  especially  hemorrhage,  and  should  always  be 
considered  in  the  face  of  this  symptom. 

Myoma  and  Fibroma  are  not  common  and  not  usually  important. 
They  are  sessile  in  attachment,  infiltrating  in  extension  and  as  else- 
where in  the  body  involve  respectively  chiefiy  the  muscular  and  fibrous 
tissue  of  the  viscus.  Commonly  only  the  microscope  will  distinguish 
the  diagnosis. 

One  of  the  earliest  possible  clinical  developments  of  papilloma  is 
shown  by  the  case  of  O'Crowley^  with  the  following  history:  The 
young  man  applied  for  examination  as  to  venereal  disease.  General 
examination  was  negative  but  cystoscopy  revealed  the  papilloma  shown 

1  Personal  communication  to  the  author,  May  4,  1917. 


ULCERATION  AND  NEOPLASM  OF  THE  BLADDER 


779 


in  Figs.  220  and  221.    lie  had  never  had  symptoms,    'i'lie  growth  was 
removed  with  a  little  sparking. 

Papillary  Carcinoma  is  solitary,  situated  at  almost  any  point,  sessile 
rather  than  pedunculated,  of  rapidly  increasing  si/.e,  at  first  nodular, 


Fig.  219. — Extensive  villous  tumor 
invisible  as  a  whole  in  one  cystoscopic 
field,  but  well  displayed  by  inspection  of 
its  right  and  left  halves.  (Marion,  Heitz- 
Boyer,  Germain. 0 


Fig.  220. — Papilloma  in  its  earliest 
stage  of  development.  Case  of  Dr. 
O'Crowley.     (McCarthy.2) 


later  necrotic  of  surface,  of  highly  lawless  outline,  always  active  in 
its  symptoms  which  embody  hemorrhagic  and  necrotic  cystitis.    The 


r 

'**  hmnillMIIHHIKF-'           ^^H 

^^B 

^  y/  j^^^jggjgjggg^l^gllj^^^^,        ,  ^^^g 

^^k 

/^JIH|PW''  ^M 

^^k 

^^^^^^^^^_ 

HH^^^^ 

^^^H 

HB 

^^^^^^^H 

Fig.  221. — -Same  as  Fig.  220.    Lens  of  cystoscope  being  in  close  apposition  and  showing 
the  striking  vascular  supply.      (McCarthy .2) 

early  forms  require  pathological  diagnosis  for  exact  decision.  Infil- 
tration of  its  annexa  is  always  a  prominent  and  diagnostic  feature 
and  may  constitute  a  distinct  variety. 


*  Loo.  cit. 


2  Tr.  Am.  Urol.  Assn.,  1915,  p.  64. 


rso 


THE  BLADDER 


Infiltrating  Carcinoma  (■i)ni])risos  the  three  tyj^es:  e])itheh()ni:itous 
hyj)rrplasia  through  (k'i;eneratit)ii  of  a  siiii})le  iileer,  iuhltratiug  hyper- 
plasia by  direct  coiitigiiitN'  from  uterine,  prostatic  and  rectal  carcinoma 
and  exuberatinj;  hyfierplasia  as  in  the  villous  and  papillary  carcinoma. 
These  three  forms  all  lune  in  connnon  ulceration.  ])roliferation  into  villi 
here  and  there,  usually  nodular,  sometimes  uniform  infiltration,  infec- 
tion, vascularity  and  (^dcma. 


Fig.  222. — Multiple  neoplasms  of  the  bladder.  Cancer  of  the  bladder  in  three  papil- 
lary outgrowths  .4,  B,  C,  separated  by  normal  mucosa,  clinically  speaking.  The  lowest 
nodule  was  near  the  neck  of  the  bladder  in  the  retropubic  quadrant  on  the  right  side, 
and  the  highest  in  the  subperitoneal  quadrant.  The  three  were  obliquely  placed  from 
above  downward  and  forward.  The  ureter  was  not  involved.  The  rounded  smooth 
part  {A)  of  the  lower  nodule  was  ob\'iously  infiltrated  and  on  section  showed  the  nature 
of  the  growth  to  be  cancerous,  as  revealed  in  the  photomicrograph.  It  had  not  yet 
begun  to  penetrate  the  muscular  coat  of  the  bladder.  The  middle  growth  (J5)  was  also 
found  to  be  cancerous  and  the  upper  growth  (C)  was  shown  to  persist  as  a  pajHlloma 
denuded  of  its  epithelium  by  the  high-frequency  current  of  its  applications.  (Author's 
case.) 


Cancer  of  the  prostate,  uterus  and  rectum  frequently  by  direct  exten- 
sion into  its  annexa  involves  the  bladder  with  an  infiltrating  hyper- 
plasia showing  little  or  no  tendency  to  ulceration,  necrosis,  vascularity 
and  edema.  Thus  while  the  bladder  is  materially  bound  down  and 
involved,  its  general  appearance  except  in  form  is  not  much  changed. 
Or  the  mass  of  such  a  cancer  presenting  toward  the  bladder  may  be 
nodular  and  show  all  the  usual  signs  of  the  disease.    Inasmuch  as  most 


ULCERATION  AND  NEOPLASM  OF  THE  HL ADDER 


781 


symptoms  of  cancer  are  at  their  acme  at  the  original  site  rather  tiian  in 
the  infiltrating  extensions,  the  foregoing  are  the  expected  facts  in  these 
circumstances  of  vesi(;al  cancer. 

Fibrous  and  Colloid  Carcinoma  are  distinguishable  from  other  forms 
only  with  the  microscope  and  are  so  rare  as  to  be  cHnically  unimportant. 

Sarcoma  may  be  of  the  infiltrating  and  noninfiltrating  type  with 
smooth  rather  than  broken  surfaces  and  of  rather  round  and  regular 
form.  Malignant  tumors  in  early  life  are  apt  to  be  sarcomata  while 
those  of  later  years,  carcinomata,  although  sarcoma  appears  not 
uncommonly  as  late  as  the  fiftieth  year  of  life.  Sarcomata  always  give 
symptoms. 


Fig.  22.3. — -Internal  aspect  of  right  and  left  halves  of  author's  case  of  extensive 
carcinoma,  primary  in  the  subperitoneal  quadrant  of  the  bladder  and  occluding  almost 
the  entire  cavity.  U.,  urethra;  P.,  prostate;  V.S.,  vesical  sphincter;  V.C.,  vesical 
cavity;  Ur.,  ureter,  greatly  hypertrophied ;  S.C,  surface  of  cancer  necrosing;  B.C.,  base 
of  cancer;  V.D.,  vas  deferens.  It  will  be  seen  how  extensive  and  infiltrating  the  mass 
of  the  growth  is.  There  was  no  cavity  left  in  which  cystoscopy  could  possibly  be 
performed,  but  the  urethra  was  not  occluded. 


Transitional  Neoplasms  are  adenomata,  mj-xomata,  myomata  and 
fibromata.  They  are  not  particularly  important  and  have  the  same 
indications  as  the  malignant  forms  so  far  as  treatment  is  concerned. 

Diagnosis  of  Neoplasm  by  Cystoscopy  in  general  must  determine  at 
least  the  following  facts:  the  presence  or  absence,  the  site  or  sites  with 
particular  reference  to  the  ureteric  mouths,  the  number,  the  tendencies 
with  special  respect  for  benignancy,  malignancy,   hemorrhage,  infil- 


782  THE  BLADDER 

tration,  ulceration  and  necrosis  and  finally-  the  relation  of  the  neoplasm 
to  its  annexa  and  the  ureters. 

The  presence  or  absence  of  a  neoplasm  of  the  bladder,  the  site  or 
sites  and  the  number  of  the  jxrowths  are  usually  readily  settled  by  a 
cystoscopy  which  reviews  the  bladder  as  a  whole  in  the  orderly  manner 
set  down  in  the  paragraphs  on  regular  plan  of  examination  of  the 
bladder  on  ]mge  742. 

Diagnosis  of  the  tendencies  of  a  tumor  as  to  bcnignancy,  malignancy, 
hemorrhaire.  infiltration,  ulceration  and  necrosis  is  throu,i2:h  cystoscopy 
often  a  difhcult  matter.  A  good  rule  is  that  when  hemorrhage  is 
present  one  should  look  upon  the  tumor  with  every  possible  means, 
such  as  direct  vision,  lateral  vision,  anterograde  and  postcrograde  cysto- 
scoi)es  and  also  the  cystourethrosco])e  when  the  growth  is  near  the  neck 
of  the  bladder. 

The  relation  of  the  tumor  to  its  annexa  and  the  ureters  is  also  of  great 
moment  inasmuch  as  the  region  of  the  ureters  is  one  of  the  commonest 
sites  of  neoplasms  and  the  efl'ect  of  the  neo])lasm  itself  first  on  the 
ureter  and  second  on  the  kidney  is  frequently  an  early  sign  of  malig- 
nancy through  congestion,  compression,  distortion,  ulceration  and 
infection  which  travels  rapidly  to  the  kidney. 

A  fragment  of  the  tumor  may  be  sheared  off  with  the  cold  wire  snare 
or  cauterized  away  with  the  high-frequency  current  or  cut  out  with  the 
Buerger  cystoscopic  rongeur  and  sent  to  a  pathologist.  The  following 
points  of  distinction  in  such  an  examination  are  important.  The  simple 
fibrous  papillomata  are  very  superficial  and  do  not  infiltrate  at  the 
immediate  base  or  annexa.  As  soon,  how^ever,  as  malignancy  appears, 
the  infiltration  begins  as  small  nests  in  the  deeper  layers  of  the  epithe- 
lium, or  penetrating  beyond  the  epithelium  into  the  muscularis,  or 
entering  the  bloodvessels,  or  underlying  the  thickening  and  edema 
around  the  base  of  the  tumor  or  associated  with  more  or  less  superficial 
necrosis. 

Siibjecti\e  history  and  symptoms  in  the  diagnosis  of  vesical  neo- 
plasm are  hardly  ever  typical  or  pathognomonic,  so  much  so  that  the 
rules  laid  down  in  older  text-books  have  been  largely  abandoned.  The 
period  of  invasion  of  neoplasm  of  the  bladder,  namely,  the  earliest  stage 
is  almost  in\'ariably  "  silent"  and  symptomless  and  therefore  misleading 
so  that  these  growths  are  frequently  discovered  incidentally  to  cystos- 
copy for  other  purposes.  Exceptionally,  however,  the  new  growth 
causes  sjinptoms  due  to  pressure  and  obstruction  of  the  ureters  giving 
a  renal  s\Tidrome  or  the  urethra  setting  up  a  vesical  synflrome.  The 
most  suggestive,  single,  early  symptom  is  hemorrhage,  sudden,  unex- 
pected and  idiopathic,  intermittent  wdth  decreasing  intervals  of  rest 
and  finally  remittent  with  increasing  periods  of  copiousness  invoking 
the  secondary  anemia  of  hemorrhage.  I  ntil  the  stage  of  constant 
hemorrhage  with  remissions  appears  most  of  the  attacks  are  sudden 
and  unprovoked. 

The  subjective  symptoms  of  the  establishment  or  extension  of  vesical 
tumor  are  much  more  though  not  finally  pathognomonic  than  those  of 


ULCERATION  AND  NEOPLASM  OF  THE  BLADDER  783 

the  early  stage  and  are  never  ".silent";  predominant  are  pains,  irri- 
tability of  the  bladder,  signs  of  foreign  body,  cystitis,  ulceration  anrl 
necrosis  with  a  secondary  urine  having  the  characteristic  odor  of  rotten 
flesh.  By  the  time  even  the  pains  and  the  irritabihty  are  present  the 
golden  moment  for  successful  operation  has  passed.  It  is  therefore 
justifiable  to  examine  the  bladder  even  when  the  susfjicion  of  such 
trouble  is  only  slight. 

Distinction  between  benign  and  malign  vesical  tumors  rests  on  the 
following  broad  principles:  The  majority  of  these  neoplasms  always 
become  malign,  although  they  may  be  at  first  benign.  In  general  early 
age  suggests  benignahcy  excepting  sarcoma  in  youth  and  malignancy 
in  advanced  life.  Solitary  papillary  tumors  are  apt  to  be  benign  while 
multiple  and  increasing  growths  of  this  class  are  of  the  opposite 
tendency.  Benign  tumors  have  normal  annexa  while  malign  growths 
infiltrate,  thicken  and  render  them  inelastic  to  distention  of  the  bladder. 
Absence  or  moderation  of  vascularity  almost  invariably  means  a  simple 
neoplasm  while  its  presence  if  marked  or  increasing  regularly  suggests 
malignancy.  The  results  of  the  neoplasm  in  the  annexa  are,  as  already 
stated,  important  so  that  malignancy  usually  means  mechanical, 
vascular  and  inflammatory  changes  in  the  immediate  surroundings  so 
that  we  early  expect  to  see  distortion,  pressure,  obstruction,  congestion, 
inflammation  and  infection  of  the  ureter  and  pelvis  of  the  kidney,  while 
around  the  growth  are  vascularity,  edema,  thickening,  inelasticity, 
infiltrations  and  fixation  in  implantation.  Thus  the  bladder,  the  ureters 
and  the  kidneys  may  be  profoundly  and  progressively  affected  by  a 
malignant  neoplasm. 

In  the  diagnosis,  moreover,  the  presence  of  superficial  sloughs  in 
the  tumor,  no  matter  how  papillary  it  may  seem,  the  infiltration  of 
the  bladder  wall  shown  in  changes  in  color,  elasticity  and  surface,  the 
presence  of  infiltration  on  bimanual  examination,  which  should  never 
be  omitted,  and  changes  in  the  dilatability  of  the  bladder  under  increase 
or  decrease  of  the  distending  medium,  are  all  important  points  in  show- 
ing malignancy.  The  presence  of  carcinoma  in ,  neighboring  organs 
such  as  the  cervix  uteri  and  prostate  should  also  be  known. 

Differential  Diagnosis. — Through  the  cystoscope  lesions  resembling 
vesical  neoplasm  may  be  studied.  These  vesical  conditions  are  confused 
with  the  less  defined  forms  of  new  growth. 

Chronic  cystitis  with  thickening  and  contracture  of  the  bladder 
presents  folds  and  rugte  which  are  thick,  prominent,  inelastic,  shaggy, 
vascular  and  often  ulcerated,  but  the  long  history  and  the  more  or  less 
universal  distribution  of  these  lesions  and  of  the  cln-onic  cystitis  are 
usually  sufficient  for  a  decision. 

Vesical  calculus,  especially  if  encysted  or  pocketed  and  only  partially 
presenting  instead  of  being  free  on  the  bladder  floor  coated  with  a 
thick  scum  of  pus  and  blood  and  margined  with  edema  and  infiltrations, 
is  sometimes  difficult  to  distinguish.  Palpation  of  the  mass,  however, 
with  the  ureteral  catheter  w411  usually  settle  the  question,  likewise  a 
radiograph. 


7S4  THE  BLADDER 

PoUipoid  edema  and  r//.s7/r  edema  about  tlie  neck  of  tlie  bladder  and 
the  mouths  of  the  ureters  are  distinguished  from  new  i^jrowth  in  not 
being  vascuhir  and  in  being  transhicent,  tense  and  smootli  instead  of 
opaque,  dense  and  rugose. 

OrganiTed  adherent  bJoodclot,  especially  in  an  ammoniacal  cystitis 
coated  with  mucopus  and  i)hosphatic  ])recipitates,  may  resemble  a 
neoplasm  but  is  distinguished  from  it  if  one  irrigates  the  bladder 
tlioroughly,  touches  the  mass  with  the  cystoscope  or  ureteral  catheter 
or  otherwise  displaces  it  from  its  adhesion. 

lljipertrophii  of  the  prostate,  es])ecially  of  the  middle  lobe  or  of 
irregular  tyjie  in  one  lateral  lobe,  is  very  difficult  to  be  sure  of  as 
distinguished  froui  neoplasm.  A  close  vision  cystoscope  is  usually 
advisable  to  note  the  absence  of  great  change  in  the  overlying 
mucous  membrane,  the  identity  of  the  mass  as  part  of  the  prostate 
and  prominence  and  protrusion  into  the  bladder  cavity  rather  than 
infiltration  and  fixation  of  the  walls  with  vascularity,  nodulation  and 
ulcers. 

Extravesical  neoplasm  is  uterine,  prostatic  or  rectal  in  its  commonest 
sites.  When  it  begins  to  affect  the  bladder  it  is  usually  by  deformation 
and  adhesion  so  that  the  mucosal  changes  within  the  bladder  are  much 
less  in  degree  as  a  rule  than  intravesical  cancer.  Such  changes  when 
present  are  necessarily  in  the  base  of  the  bladder,  including  the  trigonum. 
In  such  neoplasms  the  point  of  greatest  activity  is  at  the  primary  focus, 
in  the  uterus,  ])rostate  or  rectum  so  that  usually  the  bladder  manifes- 
tations of  the  disease  are  those  of  the  periphery  of  the  growth  with 
relati\ely  milder  symptoms  and  course. 

Treatment. — Indications  of  operation  determined  by  cystoscopy  may 
be  intra  ^•esical  or  extra  vesical  in  approach.  The  intravesical  operations 
are  performed  through  the  cystoscope  itself  or  through  similar  instru- 
ments. These  procedures  will  be  more  minutely  described  later.  They 
are  naturally  available  for  the  benign  neoplasms  alone,  such  as  pedi- 
culated,  fibropapillomata,  villous  papillomata  if  small,  and  fibromata. 
The  pedicles  remaining  should  always  be  cauterized  with  the  Oudin 
or  d'Arsonval  currents.  Extraperitoneal  cystotomy  is  applicable  for 
tumors  of  the  anterior  wall  corresponding  with  the  prevesical  space, 
while  intraperitoneal  cystotomy  is  reserved  for  neoplasms  of  the  lateral 
and  posterior  walls  and  base. 

Ilagner's^  method  is  valuable  and  ingenious.  After  preparation  of  the 
bladder  cavity  and  exposure  of  the  viscus  through  the  abdominal 
wound,  a  cystoscope  is  inserted  and  the  neoplasm  brought  into  the 
field,  especially  around  the  base.  Pressure  with  the  needle  in  a  holder 
is  made  through  the  abdominal  wound  until  a  point  is  reached  beyond 
the  infiltration  determined  by  the  cystoscopic  picture  of  the  dimpling 
in  the  bladder  made  by  the  needle.  When  a  suitable  point  is  reached 
the  needle  is  passed  widely  through  the  bladder  wall  and  the  suture 
employed  as  a  traction  suture.    Two  or  more  such  sutures  are  employed 

'  Tr.  Am.  Assn.  Gen.-urin.  Surg.,  1911,  vi,  128. 


ULCERATION  AND  NEOPLASM  OF  THE  BLADDER  785 

to  outline  the  base  of  the  tumor  for  the  excision,  and  to  secure  the 
bladder  wall  for  the  repair  suture  later. 

Total  removal  of  the  bladder  after  transplantation  of  the  ureters  into 
the  loin,  according  to  the  method  of  Watson,'  may  be  tried  in  extreme 
cases. 

Drainage  of  the  bladder  after  operation  by  the  indwelling  catheter  is 
easy  in  the  female  but  difficult  in  the  male.  The  catheter  may  be  held 
in  place  by  a  stitch  passed  through  the  meatus  urinarius,  as  suggested 
by  O'Neill. 

Squier's  Operation. — ^The  most  modern  operative  technic  for  the 
radical  extirpation  of  vesical  neoplasms  has  been  developed  by  Squier.^ 
The  growth  is  removed  en  masse  with  a  wide  encircling  margin  of 
healthy  tissue,  and  since  it  is  a  matter  of  record  that  a  functionating 
bladder  has  been  regenerated  where  only  the  trigone  has  remained  after 
an  extensive  excision,  it  is  apparent  that  it  is  only  necessary  to  conserve 
the  three  natural  orifices  of  the  bladder,  the  ureteral  orifices  and  the 
internal  meatus.  Considering  this  anatomic  trinity,  the  technic  about 
to  be  outlined  exposes  the  bladder  in  its  entirety,  and  renders  it  possible 
to  free  the  posterior  and  fundal  attachments  as  far  as  the  trigone,  with- 
out an  unusual  degree  of  hemorrhage  or  traumatism.  Seriatim,  the  steps 
are  as  follows: 

First  Step.  Skin  Incision. — From  one  inch  above  the  umbilicus  on 
the  left  side,  downward  to  two  inches  above  the  symphysis  in  median 
line. 

The  sheath  of  the  rectus  is  divided  along  the  whole  length  of  the 
skin  incision  and  the  peritoneal  cavity  opened.  The  patient  is  then 
placed  in  the  extreme  Trendelenburg  position  and  the  intestines 
gently  deposited  in  the  upper  portion  of  the  abdominal  cavity.  After 
this  the  pelvic  cavity  is  thoroughly  walled  off  by  gauze  rolls. 

Second  Step.  Exposure  of  the  Prevesical  Space. — ^Lengthen  the 
abdominal  incision  downward  through  skin  and  fascia  and  divide  the 
pyramidalis  muscles  at  the  sjonphysis,  exposing  the  prevesical  space. 

Third  Step.  Exposure  of  the  Hypogastrics. — The  peritoneum  and 
urachus  are  grasped  with  a  Barrett's  intestinal  forceps  at  the  lower 
angle  of  the  peritoneal  incision.  Upon  traction  being  made  upward, 
the  obliterated  hypogastric  arteries  are  brought  prominently  into  view 
extending  laterally  as  two  diverging  cords. 

Fourth  Step.  Exposure  of  the  Vas  Deferens. — The  left  obliterated 
hypogastric  artery  is  grasped  with  a  forceps  and  traction  made  upward 
and  to  the  right.  By  blunt  dissection  between  the  obliterated  hypo- 
gastric artery  and  lateral  wall  of  the  pelvis,  the  left  vas  deferens  is 
recognized  and  brought  into  view  as  it  courses  along  the  pelvic  wall  to 
the  inner  side  of  the  obliterated  h;^'pogastric  artery. 

Fifth  Step.  Exposure  of  the  Ureters. — By  gentle  traction  the  left 
vas  deferens  is  made  taut  and  by  means  of  blunt  dissection  downward 
along  its  course  the  peh^ic  ureter  is  uncovered  as  it  bends  inward  above 

I  Ann.  Surg.,  1905,  xlii,  p.  805. 

-  Squier  and  Heyd:    Surg.,  Gj-nec.  and  Obst.,  July,  1914,  p.  91. 
50 


786  THE  BLADDER 

the  fascia  of  the  pelvic  floor  to  enter  the  bhidder.  The  ureter  at  this 
point  is  crossed  on  its  inner  side  by  the  vas  deferens.  A  similar  exposure 
is  made  on  the  opposite  side  and  the  right  ureter  exposed. 

Sixth  Step.  Final  Scparafioj}  of  Peritoneum  frnm  the  Bladder. — The 
urachus  is  divided  close  to  the  bladder  and  from  the  two  points  of  lateral 
dissection  the  peritoneum  is  stripped  off  the  fundal  surface  of  the 
bladder.  The  denudation  extends  deep  into  the  rectovesical  space  and 
the  peritoneal  cul-de-sac  of  Douglas  is  j^ushcd  u])ward  and  backward. 
At  this  point  traction  on  the  bladder  downward  toward  the  sym])hysis 
exposes  the  superior  poles  of  the  seminal  vesicles.  The  result  of  the 
completed  denudation  is  that  the  whole  fundus  of  the  bladder  and  the 
upper  portion  of  the  posterior  surface  of  the  trigone  are  exposed;  the 
ureters  are  constantly  in  sight  and  the  anterior  or  ])ubovesical  attach- 
ments of  the  bladder  have  been  left  undisturbed.  No  hemorrhage  of 
any  moment  has  been  encountered  and  the  venous  ooze  has  been  easily 
controlled  by  hot  wet  pads. 

Sevei-ith  Step.  Protection  of  the  Peritoneal  Cavity. — The  denuded 
lamella  of  the  peritoneum  is  carefully  carried  to  the  upper  end  of  the 
abdominal  incision  so  that  all  subsecjuent  procedures  are  extra- 
peritoneal. 

Eighth  Step.  Exposure  of  Bladder  Neoplasms. — The  bladder  is 
grasped  high  up  on  the  posterior  surface  and  an  incision  is  made  in  the 
longitudinal  direction,  about  one  inch  in  length.  Through  this  opening 
an  inspection  of  the  bladder  is  made  and  the  topography  of  the  tumor 
determined.  The  incision  is  extended  in  any  direction  that  may  be 
necessary  for  proper  operative  exposure.  Since,  in  the  majority  of 
instances,  the  tumor  will  be  found  to  occupy  either  the  summit,  side, 
or  trigone  of  the  bladder,  an  incision  downward  in  the  posterior  median 
line,  which  splits  the  organ  in  half,  will  be  the  usual  incision  of  election. 

Ninth  Step.  Extirpation  of  Neoplasm. — The  neoplasm  is  excised 
en  masse,  together  wdth  a  wide  margin  of  healthy,  uninvaded  tissue  com- 
prising the  entire  thickness  of  the  bladder  wall.  The  exposure  of  the 
ureter  which  has  already  been  made  now  becomes  of  prime  importance. 
If  the  ureter  is  affected  it  is  divided  between  ligatures  above  the  growth 
and  the  distal  portion  is  removed  with  the  tumor.  The  proximal  por- 
tion is  allowed  to  remain  undisturbed  until  partial  closure  of  the  bladder 
defect  is  accomplished. 

Tenth  Step.  Closure  of  Bladder  Defect  with  Implantation  of  Ureter. — 
The  hiatus  of  the  bladder  wall  after  incision  of  the  tumor  is  partially 
repaired  as  illustrated,  the  method  of  closure  being  similar  to  the 
Connell  intestinal  suture  with  Xo.  2  chromic  catgut.  A  stab-wound  is 
made  through  the  bladder  wall  at  a  point  approximating  the  normal 
ureteral  opening  and  the  proximal  portion  of  the  divided  ureter  drawn 
through  this  opening  by  a  thin  dressing  forceps. 

Eleventh  Step.  Anchoring  the  Ureter  to  the  Bladder  Mucosa. — The 
ureter  is  brought  through  the  stab  wound  and  anchored  to  the  bladder 
wall.  About  one-half  to  three-fourths  of  an  inch  of  the  ureter  is  allowed 
to  protrude  into  the  bladder.    Two  flaps  are  made  by  bisection  of  the 


ULCERATION  AND  NEOPLASM  OF  THE  BLADDER  787 

ureteral  stump  and  the  flaps  turned  back  and  anchored  in  situ.  The 
remaining  defect  in  the  bladder  is  now  sutured  as  above  and  drainage 
of  the  bladder  instituted  by  means  of  a  stab,  button-hole  incision, 
anterior  to  the  line  of  incision  and  at  a  point  which  will  correspond  to 
the  highest  point  of  the  bladder  when  the  operation  is  cfjmplctcrl. 
Through  this  aperture  a  No.  26  F.  soft-rubber  catheter  is  drawn  and 


Fig.  224. — Implantation  of  divided  ureter  after  partial  closure  of  bladder  defect. 
(Squier  and  Heyd.) 

sutured  in  situ.  A  drainage  tube  inserted  in  this  manner  insures 
against  leakage  along  the  tube  into  the  prevesical  space, 
^Twelfth  Step.  Closure  of  Abdominal  Wound. — The  final  step  is  the 
reposition  of  the  peritoneum  over  the  vesical  suture  line  and  an  accurate 
closure  of  the  peritoneum.  If  the  peritoneum  is  invaded  by  the  growth, 
the  involved  portion  is  resected  with  the  gro^^i:h  and  the  peritoneal 


788 


THE  BLADDER 


hiatus  closed  after  the  usual  fashion,  particular  care  beinsj  taken  to 
prevent  a  ])eritoneal  suture  line  heinji:  superimposed  upon  a  bladder 
suture  line.  A  cigarette  drain  is  inserted  into  each  lateral  space  leading 
down  to  ureter  and  the  abdomen  closed  with  figure-of-eight  silkworm 
sutures.     In  addition,  a  self-retention  catheter  is  inserted. 


Fig.  225. — .Accurate  closure  of  peritoneal  cavity,  showing  the  two  cigarette  drains  and 
separate  stab-wound  for  drainage  of  bladder.     (Squier  and  Heyd.) 


Among  the  advantages  of  this  method  of  technic  may  be  mentioned : 

1.  By  primary  denudation  of  the  peritoneimi  a  free  access  to  the 
po.sterior  surface  of  the  bladder  and  trigone  is  obtained. 

2.  The  removal  of  the  tumor  is  a  removal  en  masse.  If  necessary,  the 
lymphatic  glands  along  the  lateral  walls  of  the  pelvis  and  iliac  vessels 
may  be  removed. 

3.  The  counterstab  button-hole  drainage  at  tlie  highest  point  of  the 
bladder  is  a  decided  improvement  in  technic. 

4.  The  noninterference  with  the  pubovesical  attachment  is  a  dis- 
tinct advantage  and  makes  for  rapidity  of  convalescence. 


ULCERATION  AND  NEOPLASM  OF  THE  JiL ADDER 


789 


5.  The  reposition  of  the  peritoneum  minimizes  the  leakage  and 
insures  primary  union. 

6.  The  ureters  are  constantly  in  sight  and  their  exposure  allows  a 
wide  latitude  of  operative  procedures. 

Radium  Treatment. — The  x-ray  in  the  treatment  of  cancer  of  the 
bladder  is  not  a  success  exactly  as  in  the  treatment  of  cancer  of  other 
mucous  membranes  even  when  superficial  instead  of  deep  in  a  viscus 
like  the  bladder.  The  crossfire  intensive  .r-ray  treatment  postopera- 
tively may  prove  of  greater  value. 


Fig.  226. — Ablation  of  vesical  neoplasms  with  the  cautery.  Removing  tumor  of 
posterior  wall  of  the  bladder  with  the  cautery  preliminary  to  application  of  spark. 
(Pilcher.i) 

Barringer^  has  evolved  the  following  technic  in  cancer  of  the  bladder, 
introducing  the  element  through  the  cystoscope  and  turning  the  patient 
from  side  to  side  for  contact  between  the  radium  and  the  lesion  and 
maintaining  the  contact  for  many  hours  for  penetrating  effect.  It  is  to 
be  remembered  that  the  energy  of  radium  obeys  the  law  of  all  physical 
force  and  varies  inversely  as  the  square  of  the  distance.  A  specimen 
whose  energy  is  1  will  have  fractions  of  this  force  as  the  distance  from 
the  point  of  application  increases.  Whether  this  physical  fact  is  of 
surgical  importance  remains  to  be  seen  by  time  and  experience.  The 
details  of  Barringer's  method  are  as  follow: 

"From  100  to  200  millicuries  of  radium  screened  with  0.6  mm.  of 
silver  and  1.5  mm.  of  rubber  are  put  up  so  as  to  form  a  capsule  about 

1  Tr.  Am.  Urol.  Assn.,  1915,  ix,  118. 

2  Jour.  Am.  Med.  Assn.,  November  11,  1916,  lx\-ii,  1442. 


790  THE  BLADDER 

1  iiicli  loiiiT  and  one-eighth  ineh  in  diameter;  to  this  is  attached  a  long, 
stout,  double  linen  thread.  A  direct  cystoscope  is  introduced  into  the 
bladder,  the  capsule  put  through  its  sheath  and  the  cystoscope  with- 
drawn, leaving  the  radium  in  the  bladder.  The  linen  thread  attached 
to  the  tube  runs  through  the  urethra  and  appears  at  the  meatus.  In 
women  one  may  reintroduce  a  small  cystoscope  and  see  if  the  radium 
lies  on  the  tumor.  The  patient  remahis  hi  bed  duruig  the  application. 
This,  perhaps,  is  a  crude  and  inaccurate  way  of  applying  the  radium. 
On  the  other  hand,  a  large  majority  of  bladder  carcinomas  are  in  the 
base,  and  the  tube  of  radium  cannot  be  very  far  from  a  carcinoma  in 
tliis  position;  certainly  much  nearer  than  a  rectal  or  su])rapubie  tube 
would  be.  If  the  carcinoma  is  located  on  one  side  of  the  bladder,  the 
patient  is  told  to  turn  slightly  toward  that  side  while  the  radium  is 
ai)plied.  The  patients  generally  have  l)een  able  to  urinate  without 
trouble  during  the  application.  Some  have  held  tiieir  urine  until  the 
end  of  the  irradiation,  at  most  eight  hours,  and  then  urinated  or  were 
catheterized  after  the  radhmi  was  removed.  The  urine  possibly  to 
some  extent  screens  the  vault  of  the  bladder  (all  of  my  patients  to  date 
have  had  carcuioma  of  the  base)  and  also  lifts  the  bladder  mucous 
membrane  of  the  vault  away  from  the  radium.  ^Yhateve^  may  be  the 
reason,  the  normal  bladder  mucous  membrane  seems  very  resistant  to 
radium  burns  when  the  radium  is  used  hi  this  way." 

LITHIASIS  OF  THE  BLADDER. 

General  Considerations. — A  technical  work  on  cystoscopy  must  omit 
discussion  of  the  clmical  features  of  the  process  of  lithiasis  of  the 
bladder  and  concern  itself  only  with  the  recognition  of  the  fact  of 
absence  or  presence  of  the  stone.  Given  therefore  the  syndrome  sug- 
gesting a  stone  in  the  bladder,  the  cystoscopist  concerns  himself  with 
the  actual  examination  for  it. 


Fig.  227. — "Jackstone"  calculi,  iiiue  iu  Dumber,  removed  from  the  bladder  of  a  man, 
aged  eighty-four  years.     (Case  of  Dr.  C.  Rutherford  O'Crowley.) 

The  cystoscopist  is  required  to  decide  the  occurrence  of  the  stone, 
whether  single  or  multiple;  the  size,  large,  small  or  mere  gravel; 
the  location,  vesical,  ureteral,  ureterovesical,  diverticular  or  vesico- 
diverticular;  the  mobility,  free  on  the  bladder  floor  or  immobility, 


PLATE    XII 


'^ 


■^V- 


*r 


Lithiasis  of  the  Bladder.     (Pousson  and  Carles. i) 

(Reading  froni   left  to   right). 


Urate  sand. 
Fine  urate  gravel. 
Urate  granules. 
GrantAlar  urie  aeid  stone. 


Oxalate  sand. 
Coarse    oxalate  gravel. 
Oxalate  granules. 
Rough   phosphatie  stone. 


'Encyelopedie  FraiiQaise  d'Urologie,  1914. 


LITHIASIS  OF  THE  BLADDER 


791 


attached  to  the  bladder  wall,  or  contained  within  a  ureter,  diverti- 
culum or  deep  trabeculation ;  the  origin,  renal,  ureteral  or  vesical,  by 


Fig.  228.— Multiple  vesical  and  urethral  calculi.  The  stones  were  twenty-five  in 
number,  of  which  twenty-three  were  in  the  urethra  and  two  in  the  bladder,  removed 
through  external  urethrotomy.  Calcium  oxalate  and  uric  acid  were  the  composition. 
(O'Crowley.) 


r 

--^• 

1 

\ 

f 

1 

1 

/ 

< 

V 

lian  i   ab(y 

pro'jtati 

cavity. 

Fig.  229. — Author's  case  of  lithiasis  of  bladder  and  posterior  urethra,  secondarj-  to 
prostatectomy.  The  diagram  of  the  bladder  and  urethra,  with  the  notes,  makes  the 
lesions  clear. 


792 


rilE  BLADDER 


formation  or  migration,  the  cause,  located  in  ki(lnc>-,  ureter  or  bhuUler 
by  local  disease,  det'onnity  or  anatomical  abnormality;  and  finally  the 
treatment,  viz.,  litholai)axy.  su])ra])ubie  cystotomy,  Chismore  evacua- 
tion or  fra.uinentation  with  high-frequency  current. 

Cystoscopy. — Cystoscopy  rests  on  the  foregoing  pruiciples  and  is 
ordinaril\-  standard  iji  its  details  except  in  bladders  showing  intoler- 
ance, contracture  and  deformity.  Any  and  all  these  conditions  limit 
the  degree  of  distensibility,  the  amoimt  of  medium  available  and  fre- 
quently prevent  examhiation.  In  the  foregohig  pages  on  cystitis,  the 
methods  of  overcoming  them  are  sufficiently  described.  If  all  efl'orts 
fail  the  radi()gra])h  is  the  last  resort,  and  is  frequently  valuable  to 
settle  a  d()ul)tful  diagnosis  and  should,  therefore,  never  be  omitted  in 
s\ich  circumstances. 


Fig.  230. — Lithiasis  of  the  bladder.  Conij^ouiid  stoue  in  I  he  hladder  of  a  .sixteen- 
year-old  Italian,  located  in  the  diverticulum.  Lithotripsy;  ('(nnpiefe  recovery  of  bladder; 
normal  kidneys  and  ureters.     (Author's  case.) 


The  preparation  of  the  bladder  containing  calculi  implies  irrigation 
to  cleanliness  except  in  contraindications.  Full  evacuation  of  the  blad- 
der tends  to  increase  irritability,  while  semievacuation  leaves  a  cushion 
of  fluid  behind  which  prcA'ents  the  stone  from  damaging  the  mucous 
membrane  at  flux  of  the  fluid. 

Insertion  of  the  cystoscope  should  be  very  gentle  and  ])referably 
durmg  partial  distention  only.  This  tends  to  increase  the  likelihood  of 
having  the  instrument  pass  gently  over  the  stone,  which  is  an  impor- 
tant corroborative  incident.  ^Vhen  the  cystoscope  is  easily  in  place, 
the  distention  is  brought  to  the  limit. 

The  illumination  is  now  turned  on  and  ex])l()rati()n  beguii,  giving 
most  attention  to  the  posterior  hemisphere  of  the  bladtler,  which,  in 
the  lithotomy  position,  is  inferior.  Free  stones  gravitate  into  it  and  lie 
most  commonl>'  above  the  ureters  in  the  subperitoneal  cpiadrant,  less 
commonly  in  the  ureterotrigonal  quadrant,  which,  in  women,  may 
have  a  pouch  obliterated;  in  men,  by  the  rounded  prominence  of  the 
prostate,  so  that  in  them  the  majority  of  stones  are  in  the  superior 
posterior  quadrant,  whereas  in  women  the  uterus  reverses  the  situa- 


LI  T II I  AH  I H  OF  THE  BLADDER 


793 


tion  in  many  cases.  Fixed  stones,  however,  may  }>e  located  anywhere 
in  the  bladder,  and  therefore  a  careful  cystoscopy  recjuires  going  over 
the  entire  viscus. 

The  presence  of  single  and  multiple  stones  and  of  larg<'  and  small 
stones  is  relatively  easy  except  that  gravel  cannot  ordinarily  he  counted. 

The  size  of  a  vesical  calculus  is  rather  readily  estimated,  by  counting 
the  number  of  cystoscopic  fields  required  to  cover  it  in  its  largest 
diameters  at  right  angles  to  each  other.  The  focus  must  be  maintained 
carefully,  and  the  transition  from  field  to  field  carefully  taken  by  noting 
definite  opposite  points  in  the  margins.  The  distance  between  the 
ureters  is  known  to  be  about  4  cm.,  which  is  a  convenient  measure 
often  in  the  same  process. 

The  localization  and  the  condition  of  the  stones  are  very  important. 

Free  and  movable  may  be  distinguished  from  fixed  and  immobile 
stones  by  palpation  with  the  beak  of  the  cystoscope,  ureteral  catheter, 
with  or  without  stilette,  the  operation  forceps  and  changes  in  the 
position  of  the  patient  from,  for  example,  the  exaggerated  lithotomy 
to  the  sitting  position. 


Fig.  231. — Four  stones  due  to  urethral  obstruction  and  intense  cystitis  about  eight 
weeks  after  prostatectomy.     (Author's  case  0 

Mobility  and  fixity  of  ureteral  stones  are,  moreover,  of  moment  because 
such  stones  act  reflexly  on  the  kidneys  as  obstructions  and  excite  con- 
gestion and  later  infection,  as  has  been  abundantly  proved  by  animal 
experimentation.  It,  therefore,  follows  that  all  ureteral  stones  whether 
they  present  at  the  outlet  of  the  ureters  or  not  should  be  very  carefully 
investigated. 

Immobile  stones  are  either  attached  to  the  bladder  wall,  encysted 
in  anatomical  abnormalities,  or  retained  in  the  ureters.  Attachment 
of  vesical  calculi  occurs  to  the  surfaces  of  ulcers,  stitches  m  the  bladder 
wall,  foreign  bodies  and  neoplasms  usually  in  the  form  of  incrustations. 
Encysted  and  retained  stones  occur  m  diverticula,  ureters  and  trabecidse 
of  old  prostatic  bladders.     They  may  be  of  any  form,  most  important 


1  Prostatic  Suggestions,  New  York  Med.  Jour.,  July  29,  1911. 


794 


THE  BLADDER 


of  hoiir-glrtss  shape  so  that  part  is  within  the  bhuklor  and  part  outside. 
If  tlie  neck  is  broken  the  hitter  may  remain  imdetected.  'J'he  mobility 
of  stones  within  the  ureters  is  important  because  frecjuently  they  may 
be  removed  without  a  cutting  operation  provided  instruments  may  be 
passed  beyond  them  as  hiter  described. 


Fig.  232  Fig.  233 

Figs.  232  and  233.— Multiple  shotlike  calculi  in  a  diabetic.  The  left  field  shows  the 
stones  dropping  from  the  left  ureter  toward  the  enlarged  prostate  below.  The  right 
field  shows  the  right  ureter  with  many  of  the  calculi  clinging  to  the  bladder  wall. 
(Author's  case.') 

It  is  important  to  study  the  bladder  after  the  movement  of  a  free  or 
attached  stone  by  it^lf,  palpation,  removal  or  crushing.    The  rule 


Fig.  234. — Verj-  large  mulberry  calculus  removed  from  bladder  during  prostatectomy. 

(Authoi's  case.') 

applies  in  endovesical  and  open  operations,  otherwise  conditions  in  the 
bladder  wall  will  go  mirecognized,  such  as  ulcers,  early  neoplasm  and 
foreign  conditions  like  stitches.  Treatment  of  such  underlying  con- 
ditions is  essential  and  its  reasons  obvious. 


'  Loc.  cit. 


LITHIASIS  OF  THE  BLADDER 


795 


The  origin  of  stones  in  the  bladder  is  either  formative,  due  to  local 
disease  processes,  or  migratory  from  the  upper  urinary  tract  due  to 
focal  pathology  and  then  to  transit  into  the  bladder,  or  botli  migratory 
and  formative  combined,  due  to  the  growth  througli  disease  of  the 
bladder  of  a  stone  formed  in  the  ureter  or  the  kidney  first.  Formative 
vesical  stones  or  augmentations  to  renal  and  ureteral  stones  are  due  to 
decomposition  of  urine  in  the  bladder.  Such  calcareous  deposits  may 
occur  on  any  foreign  body  such  as  masses  of  mucopus,  hair,  hairpins, 
gauze  and  the  like.  The  process  of  decomposition  and  precipitation  of 
the  urine  is  favored  by  the  existence  of  pockets,  deformities  and  inflam- 
mation in  the  bladder.  ' 


Fig.  235. — Three  stones  side  by  side,  practically  in  the  Une  connecting  the  two 
spines  of  the  ischium  and  close  to  the  shadow  of  the  coccyx,  in  a  sixteen-year-old  boy. 
(Author's  case.) 

The  common  kinds  of  stone  in  the  bladder  should  be  familiar  to  the 
cystoscopist  and  easy  of  recognition  by  him,  namely:  phosphatic,  uric 
acid  and  oxalate  stones. 

The  common  features  of  these  three  kinds  are  as  follows: 
Phosphatic  stones  are  most  common  in  alkaline  urine,  less  so  in  acid 
urine,  white  miless  blood  stained,  usually  of  roimdish  shape  but  not 
uncommonly  flaky,  single  or  multiple,  large  or  small,  soft  and  friable, 
rough  but  less  so  than  oxalate  stones,  accompanied  by  many  crystals 
in  the  urine  and  commonly  ascribed  to  vesical  origin.    Some  phosphatic 


796  THE  BLADDER 

stonrs  are  iniiiratory  from  the  kidneys  or  ureters  where  changes  in 
nietaholisin  of  the  urine  precipitate  the  salts  usually  in  solution. 

I'ric  acid  calculi  occur  in  acid  urine  often  accompanied  by -uric  acid 
and  urate  crystals  and  are  brown  with  recidish  or  yellowish  tone  laro;ely 
in  ])roportion  with  the  anu)unt  of  ilhnnination,  sin<;le  or  nuilti])le,  large 
or  small,  fretjuently  faceted  because  nudtii)le,  hard  rather  than  soft, 
ovoitl,  roujih  and  irritating  to  the  bladder  and  c|uite  frequently  are  the 
nuclei  of  phosphatic  deposits  upon  them.  Their  origin  is  usually  renal, 
especiall\'  in  those  cases  where  a  secondary  enlargement  of  i)h()sphates 
is  found. 

Oxalate  of  lime  stones  are  also  found  in  acid  in-ine,  ])r()ceed  from  the 
kidneys  as  a  rule,  are  brown  in  color  or  blackish,  being  considerably 
darker  than  the  uric  acid  deposits,  are  rough,  rarely  smooth,  consti- 
tuting the  so-called  mulberry  calculus.  The  urine  contains  many 
oxalate  crystals. 

Cvstin  st(mes  are  rare  and  are  connnoidx*  found  in  acid  urine. 


Fig.  236. — Fragments  of  calculi  after  incomplete  lithotrity.  The  smaller  fragments 
should  have  been  pumped  out  through  a  Chismore  instrument,  leaving  the  larger  pieces 
to  l>e  crushed  at  a  later  sitting.  The  bladder  wall  is  excoriated  from  the  rough  fragments 
and  covered  wdth  shreds  of  mucopus.     (Marion,  Heitz-Boj^er,  Germain.') 

Diagnosis. — The  origin  of  stones  in  the  bladder  by  cystoscopy  shoidd 
distinguish  renal,  ureteral  and  vesical  deposits.  Calculi  from  the  up])er 
urinary  tract,  the  kidney  and  the  ureter  are  in  a  certaui  sense  s\nony- 
mous  in  origin  and  may  be  distinguished  usually  by  the  .r-ray  photo- 
graph which  should  always  be  added  to  the  cystoscopy  if  there  is  any 
doubt  whate^'er. 

The  following  data  are  usually  sufficient  to  make  the  distinction  of 
the  source  of  stones  seen  in  the  bladder. 

As  to  nmnber,  size  and  form  of  the  stones,  it  is  recognized  that  these 
are  not  final  hi  the  decision.  However,  as  a  rule,  renal  stones  tend 
toward  increased  number,  smaller  size  e\'en  to  that  of  seeds  and  gravel, 
perhaps  1  mm.  in  diameter.  The  less  the  number  the  larger  the  size, 
as  a  rule,  and  the  more  ovoid  the  form  up  to  1  or  2  cm.  in  diameter. 
Vesical  calculi,  on  the  other  hand,  are  less  nimierous,  frequently  solitary, 
larger,  spheroid  rather  than  ovoid  in  form  or  irregular  and  faceted. 

'  Loc.  cit. 


LITHIASIS  OF  THE  BLADDER  797 

They  may  be  very  large  even  to  the  exclusion  of  (;y.sto.scoi>y.  Deposits 
on  foreign  bodies  are  always  of  vesical  origin. 

The  relation  of  stones  to  each  other  leading  to  changes  in  form  anrl 
facets  points  to  vesical  origin. 

The  condition  of  the  nrinc  is  im])ortant  in  this  diagnosis.  Acid  urine 
with  crystals  of  uric  acid  and  urates  usually  means  renal  origin  of  the 
larger  calculi.  Alkaline  urine,  on  the  other  hand,  with  phosphates 
suggests  vesical  source. 

The  state  of  the  bladder  is  another  interesting  detail.  Manifest 
cystitis  deformity,  abnormality,  trabeculation  and  pocketing  of  the 
bladder  all  prove  vesical  formation  of  the  deposit. 

The  color  of  the  stones  is  in  the  absence  of  blood  and  dyestuffs  of 
some  moment.  The  white  stones  are  phosphatic  and  vesical  while  the 
brownish,  blackish  and  yellowish  stones  are  more  apt  to  be  uric  acid 
and  renal. 

Treatment  and  Management. — Free  and  movable  stones  should  be 
fragmented  either  by  crushing  or  the  high-frequency  Oudin  current 
and  then,  like  small  individual  stones,  removed  with  the  Chismore 
evacuator.  Surapubic  and  the  now  nearly  obsolete  perineal  cystotomy 
are  justifiable  less  and  less  frequently. 

The  indication  is,  therefore,  to  render  all  fixed  stones  movable  and 
free  and  then  to  proceed  with  them  on  the  foregoing  recommendations. 
Attachments  may  be  loosened  with  the  cystoscope  itself,  ureteral 
catheters  with  or  without  stilettes,  or  the  Buerger  cystoscopic  operating 
forceps  and  ureteral  bougie-a-boule.  Ureteral  stones  should  be  dis- 
lodged and  delivered  from  the  ureters  by  dilation  up  to  their  site  and 
the  injection  of  sterilized  olive  oil  above,  around  and  below  them 
through  a  ureteral  catheter. 

Open  operations  are  justified  when  the  stones  are  too  large  or  too 
hard  to  crush  or  too  fixed  to  dislodge,  and  when  changes  in  the  bladder 
wall  in  cystitis  and  contracture  show  that  long-continued  dramage  will 
be  helpful. 

Postoperative  treatment  should  never  be  neglected.  Ulcers  and  growths 
having  given  attachment  to  deposits,  deformities  of  the  bladder  due  to 
prostatic  and  uterine  conditions,  and  in  general  cystitis  all  demand 
individual  appropriate  treatment.  No  patient  having  had  a  stone 
removed  from  the  bladder  or  ureter  should  be  discharged  without  a 
period  of  observation,  punctuated  with  regular  cystoscopies. 

Sources  of  error  in  cystoscopic  diagnosis  are  three:  blood  clots,  plugs 
of  mucopus  and  flaky  precipitates  and  sometimes  the  universal  change 
in  color  of  the  bladder  wall  and  contents  through  the  previous  adminis- 
tration of  methylene  blue,  for  example.  The  distinction  is  reached 
through  irrigation  especially  with  the  cystoscope  in  place  and  the 
object  under  the  eye,  through  displacement  of  it  with  various  instru- 
ments in  the  operatmg  cystoscope,  and  particularly  with  the  high- 
frequency  current.  Flaky  precipitates  are  really  calculi  with  no 
definite  form;  their  great  friability  and  irregular  more  or  less  distri- 
bution reveal  their  nature.  With  patience  and  care  no  mistakes  from 
these  sources  should  occur. 


79S 


THE  BLADDER 


Stone  Searchers. — The  tyjie  of  Posnor  has  hoon  al^andoncd  in  faAor 
of  that  of  Thompson,  which  lias  the  Hmitation  of  not  irrigating  the 
bladder  at  the  time  the  Lnstrument  is  passed.  As  an  improvement  on 
the  Thompson  instrument  the  aiitlior'  devised  the  instrument  shown  in 
Fig.  237  and  having  the  following  features:  ''  Its  curve  is  on  the  radius 
of  that  of  the  standard  sound.  shortiMUMl  1)\-  one  inch  and  flattentMl  from 


Fig.  237. — (A)  modera  model  of  Thompson's  stone  searcher;  (B)  author's  irrigating 
stone  searcher,  showing  connection  tip  of  silver  catheter,  stop-cock  and  shaft;  (C) 
obturator  of  the  catheter. 

side  to  side  throughout  its  length  from  extremity  to  shaft.  Its  extreme 
width  will  pass  through  21  French,  and  is  reduced  only  from  7  to  61 
mm.  where  it  joins  the  shaft.  The  diagram  shows  this  well  in  the  end 
view  and  side-\'iew  of  the  instrument.  The  shaft  with  the  curve  is 
9|  inches  long,  and  duplicates  the  Posner  instrument,  with  these  excep- 
tions: (rt)  There  is  no  rider  for  the  scale  of  centimeter  graduations. 
(6)  INIost  important  of  all,  a  10  French  silver  catheter  passes  from  the 
base  of  the  curve  to  the  hose-connection  in  the  handle  in  one  straight 
line,  thus  giving  to  the  instrument  all  of  the  advantages  of  the  same 


J! 

'"~^\'-'*' 

--..^^ 

Fig.  238. 


-Cystoscope,  rongeur  with  small  calculus  in  its  jaws,  withdrawn  as  one  instru- 
ment.    (Author's  case.') 


plan  laid  down  for  the  writer's  '  Irrigating  Sound  of  the  Standard  and 
Benique  Type,'  described  in  the  Annals  of  Surgery,  for  October,  1909. 
The  obturator  of  the  stone  searcher  is  a  full-size  brass  w^ire,  which  passes 
through  to  the  opening  of  the  catheter  at  the  base  of  the  curve  (see 


'  V.  C.  Pedersen:  Med.  Rec,  February  19,  1910. 
2  Loo.  cit. 


FOREIGN  BODIES  IN  THE  BLADDER  799 

C  of  Fig.  237).  At  this  point  it  is  convexed,  while  the  catheter  is 
concaved,  in  order  to  correct  any  sharp  edges  or  comers. 

"The  tube-connection  (B)  receives  f  inch  diameter  rubber  tubing 
and  seats  the  obturator  in  a  modified  bayonet-catch.  The  slot  of  this 
catch  and  the  plug  (A)  of  the  obturator  setting  into  the  slot  are  so 
arranged  that  the  sharp  oblique  point  of  the  obturator  cannot  possibly 
be  exposed  as  M  through  the  tube.  This  detail  adds  safety  in  the  use 
of  the  instrument. 

"The  advantages  for  this  instrument  are:  that  it  may  be  used  either 
for  an  irrigating  or  nonirrigating  searcher,  that  its  flat  beak  permits 
diagnosis  of  small  stones  with  greater  certainty,  that  its  straight,  large 
tube  permits  of  rapid  and  full  irrigation  of  the  bladder  when  required, 
and  also  much  more  adequate  cleansing  and  asepsis  of  the  instrument." 

FOREIGN  BODIES  IN  THE  BLADDER. 

A  large  variety  of  foreign  bodies  occur  in  the  bladder  through 
accident,  criminal  intent  and  sexual  perversion.  The  cystoscope  is  the 
best  means  of  diagnosis  in  the  midst  of  symptoms  which  closely  simulate 
those  of  stone.  Such  bodies  rapidly  become  incrusted  with  salts  of 
lime  or  other  urinary  constituent  and  are  thereafter  truly  vesical  con- 
cretions. Fig.  241  shows  a  piece  of  irrigation  nozzle  broken  by  a 
colleague  while  irrigating  a  bladder  through  the  cystoscope  previously 
reported  by  the  author  as  cited.     A  piece  of  catheter  had  previously 


Fig.  239. — Foreign  body  in  the  bladder.  Hairpin,  incrusted  with  phosphatic  salts 
and  embedded  in  a  point  of  bullous  edema  of  the  wall  as  part  of  active  cystitis. 
(Marion,  Heitz-Boyer,  Germain.^) 

been  broken  off  in  a  bladder  by  a  nurse  but  was  recovered  by  Dr. 
Gouley  by  means  of  a  lithotrite  in  1893,  practically  before  the  days  of 
modern  cystoscopy,  and  illustrating  the  skill  possible  with  such  instru- 
ments. Fig.  239  shows  a  hairpin  introduced  into  the  bladder  by  a 
woman  probably  during  sexual  perversion  and  lost.  The  thick  coating 
phosphates  illustrates  the  course  of  such  foreign  substances  in  the 
urinary  system. 

1  Cystoscopie  d'Exploration,  1914. 


800 


THE  BLADDER 


Fig.  240. — Chewing  gum  removed  from  the  male  bhidder.  Seven  fragments  are  shown 
about  full  size.  Five  were  removed  with  the  Chismore  lithotrite  and  two  -n-ith  the  Chis- 
more  pump.  Incrustations  of  urinary  sediment  are  visible  on  at  least  three  of  the  larger 
fragments.  Tooth-marks  of  the  lithotrite  are  reasonably  clear  on  the  largest  pieces. 
(Author's  case.)  ^  ^_; 


Hi- 


4 


Fig.  241. — Glass  fragment  of  irrigating  nozzle  extracted  from  bladder. 


PLATE    XllI 


Purpura  Hemorrhagica  of  the  Bladder.     (Bruni.i) 

Diffuse   lesions,   both    new  and    old,  with  a   few  very   sniall   punctate 

exannples. 


1  Marion,  Heitz-Boyer,  Germain:  Cystoscopie  d 'Exploration.   1914. 


RARE  FORMS  OF  DISEASE  OF  THE  BLADDER  801 

RARE  FORMS  OF  DISEASE  OF  THE  BLADDER. 

Classification. — The  usual  types  of  disease  of  the  bladder  are  difficult 
of  classification  except  in  the  most  general  way  as:  anatomical,  cir- 
culatory, inflammatory,  parasitic  and  traumatic.  A  brief  discussion  of 
each  is  possible  in  a  work  like  this. 

Anatomical  Rare  Forms. — Anatomical  rare  forms  concern  rather 
the  extremes  of  the  conditions  commonly  met  in  bladders  showing 
trabeculations,  pouches  and  diverticula,  all  and  severally  due  more 
or  less  to  obstruction  as  in  prostatics,  or  to  atony  of  the  bladder  as  in 
advanced  age  in  both  sexes,  or  to  paresis  or  paralysis  of  the  bladder 
as  in  organic  spinal  disease  most  especially  posterior  spinal  sclerosis. 
Associated  lesions  are  almost  invariably  great  distention  and  chronic 
cystitis.  Many  of  these  anatomical  conditions  are  of  progressive  occur- 
rence as  real  sequels  of  cystitis,  obstruction  and  paralysis. 


Fig.  242. — Varix  in  the  trigonum.     The  large  vessel  is  shown  but  none  of  the  small 

fibrillations.      (Knorr.^) 

Circulatory  Rare  Forms. — Circulatory  rare  forms  are  summed  up  in 
varicosities  more  marked  in  degree  and  more  persistent  in  course  than 
those  seen  during  acute  or  subacute  conditions.  Examples  of  acute  and 
subacute  varicosities  proceed  from  obstruction  of  the  uretlira  as  in 
abscess  of  the  prostate  and  are  really  an  ascent  from  congestion.  More 
chronic  varicosities  occur  in  disease  of  the  heart,  kidneys  and  liver  and 
in  pregnancy,  all  due  to  mechanical  obstruction  commonly  at  points 
distant  from  the  bladder.  The  failing  circulation  of  old  age  is  another 
factor.  Varicosities  show  themselves  as  groups  of  dilated  veins  usually 
in  association  with  the  affecting  organ  such  as  the  prostate. 

Purpura  Hemorrhagica. — Purpura  hemorrhagica  of  the  bladder  is  a 
rather  rare  but  important  condition  associated  with  purpura  and  having 
the  following  characteristics:  The  urine  is  full  of  clotted  and  fluid 

1  Loc.  cit. 
51 


S02 


THE  BLADDER 


blood  fully  mixed  with  the  urine,  appearing:  in  attacks  and  in  asso- 
ciation with  more  or  less  pain  during  the  actual  bleeding.  A'-ray 
examination  is  necessarily  negative.  Cystoscopic  findings  show  healthy 
ureters,  the  mucous  membrane  normal  and  pale  if  the  bleeding  has 
been  great,  but  showing  irregularly  disposed,  formed  and  sized  typical 
purpuric  patches.  The  tendency  is  for  them  to  be  most  numerous  in 
the  lower  and  upper  posterior  segments.  Ulceration  is  absent.  Sys- 
tematic cystoscopic  examination  of  patients  with  purpura,  showing 
hematuria,  will  probably  bring  to  light  a  really  largo  number  of  these 
cases. 


Fiu.  24.3. — Small  diverticulum  of  the  bladder.  The  zebra  catheter  passes  into  the 
kidney  while  the  bi.smuth  catheter  delivered  the  argyrol  into  the  diverticulum.  (.\uthor's 
case.) 


Inflammatory  Rare  Forms. — Inflammatory  rare  forms  are  exemplified 
by  the  leukoplakia  vesicae  of  Knorr  which  is  cognate  with  leukoplakia 
linguae  and  like  it  is  the  product  of  chronic  infiltrating  inflammation  of 
the  mucous  membrane.  It  consists  of  hypertroj^hy  of  the  epithelium 
in  plates  with  sharp  borders  closely  attached  to  the  underlying  struc- 
tures. The  exact  cause  is  unknown  excepting  that  it  occurs  during  or 
after  chronic  cystitis  and  is  at  times  idiopathic.  Its  s\TTiptoms  are  those 
of  chronic  cystitis,  namely,  dy.suria,  pollakiuria,  pyuria  and  hematuria. 


RARE  FORMS  OF  DISEASE   OF   THE  BLADDER 


803 


Parasitic  Diseases.— Parasitic  diseases  of  the  bladder  consist  of 
chiefly  echinococcus  and  distoma  hematobium,  (Bilharz).    'J'he  author^ 


Fig.  244. — Small  diverticulum  of  the  bladder.     The  bismuth  catheter  has  turned  upon 
itself  and  is  presenting  at  the  ureteric  orifice.     (Author's  case.) 


Fig.   245.— Left   ureter  filled   partially  with   collargol.      Bladder   filled   with   collargol. 
Constriction  between  the  two  shadows  represents  the  diverticular  orifice.    (Young.) 

1  V.  C.  Pedersen:   New  York  Med.  Jour.,  Maj-  3,  1913. 


804  THE  BLADDER 

ha>^  poiiitt'd  (Mit  olsewliere  that  urinalysis  will  reveal  the  dauu-hter  cysts 
and  the  hooklets  of  echinococcus  and  also  the  ova  of  bilharziosis.  This 
fact  is  sufficient  for  dismissal  of  echinococcus,  but  there  is  more  impor- 
tance to  be  attached  to  consideration  of  bilharziosis  which  is  due  to 
infection  in  the  tropics  with  the  distnnin  hcmdiuhium  (Bilharz).  The 
disease  is  endemic  in  Ky;>i)t  and  Cape  Colony  and  is  assumin»]j  more 
and  more  imj)ortance  as  the  number  of  toiu'ists  and  hunters  in  Africa 
increases.  E.  Hurry  Femvick,  for  example,  states  that  subsequent  to 
the  cani])ai,ij;ns  in  Egypt  and  South  Africa  the  disease  has  become  not 
unconnnon  in  Eiifrland.  The  following  description  is  adopted  from  his 
quotation  from  (iriesinger's  work.^  It  is  a  disease  of  the  vesical, 
ureteral  and  renal  mucosa  and  not  of  the  muscularis.  It  may  be  classi- 
fied into  early  mild  cases,  later  severe  cases,  both  of  inflammatory  type, 
severer  cases  of  vegetating  ty])e  and  chronic  cases  of  pigmented  type. 

The  early  mild  cases  are  usually  localized,  occasionally  disseminated 
chiefly  over  the  posterior  wall  of  the  bladder  in  hj^Dcremic  spots  varying 
up  to  2  cm.  in  diameter,  with  defined  or  congested  borders,  extrava- 
sation, edema,  coatings  of  thick  mucus  or  sanguineous  exudate  fre- 
quently containing  ova  and  having  ulcers  beneath.  Generalized  infec- 
tion of  the  bladder  cavity  is  rare  and  then  has  marked  inflammation 
with  frequent  ecchymosis.  Ulceration  of  distinct  type  in  this  degree  is 
rare. 

The  later  more  severe  cases  take  on  the  productive  inflammatory 
form  and  show  ele\'atio]is  of  grayish-yellow,  yellow,  dull  white  or  other- 
wise pigmented  color,  coatings,  leather-like  in  consistency,  smooth 
apparently  below  the  surface,  having  a  precipitate  non-adherent  and 
consisting  of  urinary  salts,  ova  and  shells  of  ova,  all  incorporated  with 
the  epithelial  covering  which  comes  away  with  it.  Other  patches  are 
soft,  })liable  and  hemorrhagic.  Pigmented  patches  of  dirty,  red,  gray, 
or  black  color  in  the  midst  of  mucosa  otherwise  normal  excepting  for 
new  and  progressing  deposits  are  also  seen  m  these  cases.  In  this 
stage  ulcerations  of  the  character  beneath  the  coatings  may  occur  but 
are  rare.  The  distoma  is  found  in  the  neighborhood  of  the  bloodvessels 
in  little  sacks  connecting  with  them  and  the  eggs  .are  usually  in  the 
infiltrated  submucosa  from  which  they  rupture  into  the  bladder  with 
bleeding  when  the  bladder  closes  upon  itself  at  the  end  of  urination. 
From  this  it  follows  that  the  terminal  bleeding,  if  any,  contains  the  ova. 

The  severer  vegetating  type  resembles  the  foregoing  excepting  in  the 
fact  that  the  productive  element  of  the  inflammation  is  exaggerated  so 
that  all  varieties  of  elevations  occur  from  flat  and  sessile  to  elevated  and 
prominent,  single  and  multiple,  pea  to  bean  size,  yellowish  or  ecchy- 
motic,  often  raised,  warty  and  fungoid  with  restricted  basis,  like 
condylomata  acuminata.  Often  the  mucosa  over  them  is  normal  but 
more  usually  thick  and  adherent.  They  may  be  injected,  dark  red 
with  submucous  edema  or  soft  yellow  brown  and  brittle  or  firm  and 
hifiltrated  with  coagulated  blood. 

'  A  Handbook  of  Clinical  Electric-light  Cystoscopy,  by  E.  Hurry  Fenwick,  F.R.C.S., 
J  904,  pp.  .530  to  5.34,   inclusive. 


BARE  FORMS  OF  DISEASE  OF  THE  BLADDER  805 

The  muscularis  is  unchanged  except  along  the  lin(;s  of  hypertrophy 
due  to  the  cystitis.    Tlie  distoma  rarely  invad(;s  it. 

The  peritoneal  coat  of  the  bladder  also  escapes,  although  one  case 
has  been  reported  showing  pigmentations  and  thickenings. 

Bilharz  found  the  distoma  in  the  submucosa  of  the  vegetations  in 
smooth  walled,  cyst-like  p()ck(!ts  having  connections  with  the  blood- 
vessels. 

The  mucosa  of  the  ureters  and  pelves  of  the  ureters  show  similar 
changes.  In  the  ureters  are  found  irregular  islands,  yellowish,  slightly 
prominent,  with  soft,  adherent  sandy  coating  and  containing  ova  and 
cysts  in  the  walls.  Their  important  sequels  are  stricture,  dilatation, 
hypertrophy  of  the  ureter  and  congestion  of  the  kidney. 


Fig.  246  Fig.  247 

Fig.  246. — Pelvic  abscess  ruptured  into  the  bladder.  The  pelvic  abscess  was  of 
unknown  origin,  situated  on  the  left  side  of  the  patient,  ruptured  into  the  bladder, 
caused  cystitis  and  simulated  diverticulum.  Cured  by  operation  by  Dr.  J.  Bentley 
Squier,  Jr.,  as  stated  in  Fig.  247.     (Case  of  Dr.  N.  P.  Rathbun.') 

Fig.  247. — Pelvic  abscess  ruptured  into  the  bladder.  This  is  the  same  case  as  that 
shown  in  Fig.  246.  At  operation  the  abscess  appeared  to  come  from  the  acetabulum. 
This  picture  has  not  been  corrected  so  that  the  shadow  appeared  to  be  on  the  patient's 
right  side.  Kidney,  ureters  and  bladder  negative  to  x-ray.  (Case  of  Dr.  J.  Bentley 
Squier.2) 

The  frequency  of  travel,  exploration  and  hunting  expeditions  in 
Africa  and  Cape  Colony  makes  this  disease  more  and  more  important 
in  communities  of  the  temperate  zones.  Anyone  returning  from  such 
a  trip  with  the  symptoms  of  penile  pain,  irritability  of  the  bladder, 
hematuria  and  cystitis  should  be  suspected  of  having  the  disease.  And 
the  last  drops  of  his  blood  should  be  examined  for  the  ova  of  the 
distoma.  The  prognosis  of  the  disease  may  largely  be  estimated  by 
cystoscopy  in  terms  of  the  severity  of  the  process  as  previously 
described.  Bits  of  vegetation  and  other  deposits  may  be  removed  for 
examination  with  the  forceps  of  Buerger. 

1  Case  report  presented  at  the  meeting  of  the  New  York  Society  of  the  Am.  Urol.  Assn., 
February  2,  1917,  and  previously  unpublished. 

2  Ibid. 


806  THE  BLADDER 

Traumatic  Rare  Forms. — Traumatic  rare  forms  are  summed  up  as 
ri'sults  of  injury.  i>i)(.'ration  and  ]iressure  necrosis  resultinu'  most  com- 
nioidy  in  fistula  antl  less  usually  in  sinij)le  sear  tissue.  Subsecjueut 
healini;;  of  the  fistula  and  contracture  of  the  scar  often  lead  to  deformity 
of  the  bladder.  Diagnosis  in  such  deformity  rests  on  the  objective 
examination  of  the  bladder  with  the  cystoscope  and  carefully  taken 
history.  Common  sites  of  such  lesions  are  between  the  bladder  and 
the  abdominal  wall  after  su])rai)ubic  cystotomy,  between  the  bladder 
and  the  perineum  after  perineal  cystotomy,  between  the  bladder  and 
the  vagma  or  the  uterus  after  the  accidents  of  childbirth  and  occasional 
operations  and  finally  between  the  bladder  and  intestines.  Very  rarely 
such  ])athological  conditions  as  dermoid  cysts  may  rupture  into  the 
bladder  and  their  abnormal  contents  appear  there  as  the  nuclei  of 
calculi.  For  example,  E.  Hurry  Fenwick  reports  a  case  in  which  tubal 
pregnancy  with  a  dead  fetus  of  su])posedly  years'  duration  residted  in  a 
fistida  between  the  sac  and  the  bladder  and  the  sac  and  intestine,  "^riie 
writer  has  had  a  case  of  fistula  after  a  prostatic  abscess  ()i)eration  with  a 
limb  opening  into  the  bladder  and  another  into  the  urethra.  So  long 
as  the  fistulous  opening  into  the  bladder  is  inflamed  or  infected  it  is 
surrounded  by  a  red  edematous  zone.  The  same  condition  is  found 
around  a  partially  healed  wound  of  the  bladder.  When  the  recovery  is 
established  a  scar  remains  with  some  deformity  of  the  bladder  wall 
and  cavity.  During  the  activity  of  a  fistula  into  the  intestines,  fecal 
matter  may  be  seen  to  pass  out  of  it  into  the  bladder  or  urethra,  as  the 
case  may  be.  Fenwick  states  that  in  his  case  foul  products  from  the 
dead  fetus  were  seen  in  and  recovered  from  the  bladder.  The  diagnosis 
of  fistulas  between  the  bladder  and  the  surrounding  organs  must  not 
rest  on  cystoscopy  alone  but  should  be  corroborated  as  far  as  possible 
by  a  suitable  examination  of  the  other  organ  aft'ected,  hence  proctos- 
copy and  vaginoscopy  and  the  like  shoidd  always  be  resorted  to 
combined,  for  example,  with  injection  of  the  fistulous  tract  with 
methylene  blue,  for  example,  if  practicable. 

Collargol  may  be  injected  into  the  bladder  through  the  cystoscope 
and  a  plate  as  shown  in  Fig.  245  then  obtahied.  Young, ^  in  the  article 
quoted,  describes  the  collargol  injections  as  follows:  "Collargol,  15 
per  cent.,  was  then  injected  through  each  ureter  catheter  and  radio- 
graphs taken.  The  right  renal  pelvis  appeared  considerably  dilated 
and  irregular,  the  ureter  slightly  dilated  from  kidney  to  bladder,  and 
the  kidney  enlargerl.  The  left  kidney  and  lu'eter  show  no  shadows,  but 
just  above  the  bladder  in  the  left  side  of  the  body  pelvis  a  large  fusiform 
shadow  is  sho\Mi  (which  was  supposed  to  be  the  diverticulum — the 
supposition  being  that  the  catheter  had  slipped  out  of  the  ureter  and 
was  coiled  up  in  the  diverticulum)." 

THERAPEUSIS  OF  THE  BLADDER  IN  CYSTOSCOPY. 

General  Considerations. — Diagnosis  of  conditions  in  the  bladder  in 
cystoscopy  was  considered  from  the  standpoints  of  infiammation, 

>  Tr.  Am.  Urol.  Assn.,  1912,  vi,  161. 


THERAPEUSIS  OF  THE  BLADDER  IN  CYSTOSCOPY         H(}7 

foreign  b(xlies,  neoplasms,  iibiiorrnalities  and  aids  in  operation.  TlxTa- 
peusis  of  the  bladder  will  be  diseussed  in  the  sani(;  order  of  subjeets. 

The  procedure  of  the  use  of  the  cystoscope  in  the  treatment  of  the 
bladder  is  much  the  same  as  in  ordinary  cystoscopy.  The  medium  may 
be  water  or  air,  as  the  oceasioji  demands,  with  the  reservation,  however, 
that  a  number  of  deaths  have  occurred  from  air  dilatatioji,  seemingly 
through  absorption  of  the  air  in  large  quantities  })y  the  bloodvessels 
and  its  circulation  as  bubbles  in  the  blood.  It  is  at  least  necessary, 
therefore,  to  follow  the  precautions  of  employing  as  little  air  as  possible 
not  under  pressure  in  the  bladder  and  for  the  briefest  possible  time. 
Oxygen  is  a  much  better  substitute. 

Therapeusis  of  Inflammations. — The  therapeusis  of  inflammations 
arises  from  the  indications  for  direct  application  of  chemical,  thermal, 
electrical  and  mechanical  means  in  cystoscopy. 


Fig.  248. — Infantile  bladder.  The  feature  is  a  long  prolongation  in  the  urachal  or 
apical  quadrant  of  the  bladder  terminating  in  a  cavity  called  infundibulum  urachi, 
difficult  to  illuminate  even  in  extreme  distention,  and  elevation  of  the  lamp  toward  it. 
(Marion,  Heitz-Boyer,  Germain.) 

The  instruments  available  are  any  of  the  well-known  urethroscopes, 
such  as  Kelly's,  Chetwood's  and  Young's,  and  any  of  the  direct-vision 
cystoscopes  such  as  Braasch's,  F.  Tilden  Brown's,  Lewis's  operation, 
the  Acmi  convex  sheath  operation  and  the  Buerger  operation  cysto- 
scope with  their  accessory  equipment  of  small  instruments  and  the 
high-frequency  current  generator  and  switch. 

The  lesions  of  inflammation  for  therapeusis  in  cystoscopy  are  chiefly 
disseminated  cystitis,  simple  ulcers,  and  single  or  few  small  tuberculous 
deposits  or  ulcers. 

Disseminate  Cystitis. — Disseminate  cystitis  occurs  m  localized  patches 
confined  to  small  or  scattered  over  large  parts  of  the  bladder.  These 
may  be  through  a  cystoscopic  tube  or  a  direct-vision  cystoscope,  freed 
of  their  coating  of  pus  and  detritus  and  then  treated  with  solutions  of 
nitrate  of  silver  in  percentages  from  1  per  cent,  to  10  per  cent,  followed 
by  irrigation  with  normal  salt  solution. 

Simple  Ulcers. — Simple  ulcers  may,  through  the  same  instruments, 
be  treated  in  much  the  same  manner  as  the  spots  of  disseminated 
cystitis,  or  they  may  also  be,  through  one  of  the  operation  cysto- 


808  THE  BLADDER 

scopes  curetteil  or  freshened  with  tlie  rongeur  or  stimuhited  or  lightly 
cauterized  with  the  Oudui  high-frequency  current,  thus  fulfilling  the 
indication  of  establishing  a  new  base  so  far  as  possible  whieh  may 
take  on  healing  qualities. 

Tuberculous  Deposits  or  Ulcers,  single  or  few,  may,  through  the 
operation  cystoseopes,  be  removed  both  ft)r  diagnosis  and  cure.  The 
bases  of  such  lesions  left  behind  should  be  well  cauterized.  Larger 
tuberculous  (lei)osits  require,  in  the  opinion  of  some  authorities,  fairly 
active  thermoeanterization  through  the  tui)e  or  eleetrocauteri/.ation 
with  the  high-frequency  current,  or  in  the  judgment  of  other  authori- 
ties, open  operation  and  treatment  according  to  indication.  The 
latter,  however,  seems  to  be  in  the  lesser  faA^or,  because  cutting  oper- 
ations rather  favor  spread  of  the  bacilli  through  the  system.  A  most 
important  detail  in  all  these  tuberculous  cases  is  a  recognition  and 
treatment  of  the  i)rimary  focus. 

Therapeusis  of  Foreign  Bodies. — Therapeusis  of  foreign  bodies 
arises  from  syni])toms  and  diagnosis  in  cystoscopy  suggesting  their 
presence.  Small  calculi,  fragments  of  calculi  after  crusliing  oi)erations, 
pieces  of  broken  instruments  ami  material  introduced  through  per- 
versions of  the  sexual  instinct  are  all  included.  They  all  tend  to  set 
up  cystitis  and  to  augment  in  size  through  precipitation  of  urinary 
salts  upon  them  so  that  foreign  bodies  which  might  have  been  readily 
removed  with  simpler  require  graver  means. 

The  Lnstrmnents  available  are  the  Buerger,  Brown  or  Lewis  opera- 
tion cystoscope  and  outfit,  the  author's  suction  attachment  for  either 
of  the  foregoing  instruments,  Chismore's  evacuation  outfit,  Young's 
or  Walker's  cystoscoi)ic  lithotrite,  Thompson's  lithotrite  preceded  and 
followed  by  cystoscopy. 

The  cystoscopic  lithotrite  is  a  comparatively  new  instrument  whose 
forerimners  were  instruments  of  the  same  type  devised  by  Albarran, 
Nitze  and  Bierhoff.  The  first  was  fragile  and  the  last  two  were 
imperfect  in  obscuring  the  object  with  the  jaws. 

Calculi. — Small  calculi  or  fragments  of  larger  calculi  after  litho- 
lapaxy  or  pieces  of  instruments  may  be  removed  with  forceps  through 
an  operation  cystoscope,  or  sucked  out  with  the  author's  evacuation 
attachment  or  a  Chismore  tube.  The  manner  of  usiiig  the  author's 
evacuator  is  that  when  the  object  is  carefully  in  the  cystoscopic  field 
with  the  instrument  placed  with  the  beak  laterally  flat  on  the  bladder 
floor  the  light  is  extinguished,  the  telescope  is  removed  and  the  evacua- 
tion valve  and  bulb  attached  and  the  pumj^ing  begun.  Thus  the 
fenestrum  of  the  cystoscopic  sheath  is  very  near  the  object  before  the 
evacuation  is  attempted. 

Larger  calculi  or  fragments  requiring  reduction  in  size  may  be 
located  with  one  of  the  cystoscopic  lithotrites  with  the  aid  of  vision  and 
then  crushed  and  removed,  or  recognized  in  the  usual  way  with  the 
Thompson  lithotrite  or  one  of  its  cognates  and  then  crushed  and 
evacuated.  Cystoscopy  should  always  be  part  of  these  operations, 
either  through  the  telescope  of  the  lithotrite  or  of  a  cystoscope  sub- 
sequently introduced. 


THERAPEUSIS  OF  THE  BLADDER.  IN  CYSTOSCOPY         809 

Soft  foreign  bodies  like  pieces  of  catheter  which  might  break  or  oth(!r- 
wise  be  inconvenient  may  be  seized  in  the  forc(;ps  and  engaged  in  the 
fenestrum  of  the  sheath  and  every  tiling  withdrawn  tog(;ther. 

Therapeusis  of  Neoplasms. — Therapeusis  of  neoplasms  in  cysto- 
scopy is,  in  general,  contraindicated  I)y  malignant  tumors  of  all  classes 
owing  to  the  somewhat  restricted  facility  of  aj)proach  which  the  cys- 
toscope  affords,  and  in  the  opinion  of  many  authorities  contraindicated 
by  multiple  growths  of  benign  character  because  of  the  definite 
tendency  these  have  toward  malignancy. 

The  indications  of  such  therapeusis  are  prostatic  hypertrophy 
localized  in  the  neck  of  the  bladder  as  the  so-called  "  bar"  and  in  jjcdun- 
culated  outgrowths  of  the  middle  and  sometimes  lateral  lobes.  The 
writer  has  a  case  in  which  a  small  pedunculated  enlargement  of  the 
middle  lobe  acted  as  a  ball-valve  in  the  bladder.  It  was  removed  by 
suprapubic  cystotomy  undertaken  for  the  purpose  of  removing  the 
prostate  as  a  whole  also.  In  the  exposed  bladder  this  was  found 
unnecessary  so  that  the  operation  might  have  been  made  intravesically 
through  the  cystoscope.  The  most  common  indication  is  papillomata, 
single  or  multiple,  if  not  too  numerous  or  extensive.  Some  authorities 
believe  that  very  early  malignancy  is  another  possible  indication. 

The  instruments  applicable  are  Young's  prostatic  punch,  the  Buerger 
or  Acmi  operation  cystoscope,  Oudin  high-frequency  current  apparatus, 
Nitze's  cystoscopic  electric  cautery,  Nitze's  cystoscopic  electric  snare, 
and  Young's  cystoscopic  rongeur. 

The  prostatic  bar  and  pedunculated  small  enlargements  of  the  middle 
and  lateral  lobes  were  originally  treated  by  the  Bottini  operation  with 
the  danger  of  absent  drainage  and  later  by  the  Chetwood  galvano- 
cautery  knife  with  the  added  safety  of  drainage.  Neither  of  these 
operations  seems  to  give  permanent  results.  The  cystoscope  permits 
approach  to  these  lesions  under  the  eye  so  that  they  may  be  snared  off 
with  the  hot  or  cold  wire  or  ablated  with  the  Nitze  electric  cautery  or 
in  the  case  of  the  bar  a  fragment  may  be  removed  with  Young's  pros- 
tatic punch,  which  is  in  high  favor. 

Papillomata  of  the  bladder,  single  or  multiple,  are  treated  best  with 
the  high-frequency  current  of  Cudin  m  the  method  discovered  and 
developed  by  Edwin  Beer,  of  New  York,  who  describes  his  technic  in 
the  following  words:  "The  essential  instruments  for  this  therapy  are: 
(1)  a  high-frequency  machine  with  Oudin  resonator,  (2)  a  catheterizing 
cystoscope,  (3)  a  heavily  insulated  copper  electrode.  Instead  of  the 
induction  coil  and  interrupter  the  latest  model  instrument  uses  a  closed 
magnetic  field  transformer  ('step-up')  which  gives  more  rapid  oscil- 
lation and  can  be  employed  in  any  room  effectively."  Beer^  further 
goes  on  to  discuss  the  actual  details  of  applications  as  follows : 

"  The  applications  were  made  directly  to  the  growth,  the  electrodes 
being  pushed  a  short  distance  in  among  the  villi  under  the  guidance  of 

1  Jour.  Am.  Med.  Assn.,  May  28,  1910,  liv,  1768  and  1769;  Am.  Surg.,  1911,  liv.  208; 
Jour.  Am.  Med.  Assn.,  November  16,  1912;  lis,  1784  and  1785;  Med.  Rec,  February  8, 
1913;  Am.  Surg.,  June,  1915. 


810  THE  BLADDER 

the  eye,  and  then  tlie  current  was  turned  on  at  various  points  for 
fifteen  to  thirty  seconds,  the  i)hul(.ler  being  distended  with  distilled 
water.  In  my  early  seances  1  made  the  treatments  rather  short.  The 
longest  total  applications  that  I  have  used  at  one  seance  aggregated 
ten  minutes,  thirty  seconds  at  twent>'  different  spots.  This  was  an 
enormous  tumor  and  so  long  an  a])])lieation  surely  is  not  necessary 
except  in  such  cases.  A  total  of  three  to  ti^■e  minutes  at  one  sitting  will 
suttice  usually.  A  few  days  later  it  should  be  repeated,  provided  any 
viable  tumor  tissue  is  visible,  as  at  the  original  sitting  it  is  impossible 
to  iletermine  how  extensively  one  lias  destroyed  the  growth.  Treat- 
ments are  discontinued  as  soon  as  the  whole  growth  a])))ears  necrotic. 
The  sloughs  are  allowed  to  separate  spontaneously  or  helped  along  with 
bladder  irrigations.  After  the  base  is  thus  exposed  (after  t^^'o  to  three 
weeks)  it  is  treated  as  were  the  original  outgrowths." 

The  Oudin  high-freciuency  current  is  monopolar.  A  bipolor  current 
is  meeting  with  favor  with  some  operators,  for  example,  Kiittner'  and 
Keyes.-  The  actual  cautery  may  be  applied  through  a  direct-vision 
cystoscopic  sheath,  while  Nitze  has  produced  a  cystoscopic  electro- 
cautery which  is  available  in  some  cases.  Very  recently  Buerger^  has 
})r()duced  a  series  of  \'aluable  instruments  for  operation  })urposes  con- 
sisting of  a  rongeur  forceps  and  a  cold  wire  snare.  Nitzc''  has  a  hot  wire 
snare  produced  through  an  electric  current  made  to  pass  through  it. 
Yomig^  has  a  large  rongeur  of  two  blades  meeting  so  as  to  be  like  a 
sound  or  cystoscope  in  shape.  An  inspection  telescope  passes  through 
their  shafts  after  the  mstrument  is  in  place  and  permits  the  o])erator 
to  bite  off  fragments  of  the  growth  within  the  field  of  the  mstrument. 

A  most  important  function  of  the  cystoscope  in  neoplasms  of  the 
bladder  is  the  securing  of  fragments  for  the  pathologist.  The  operation 
cystoscope  "is  required,  through  which  the  Buerger  cystoscopic  rongeur 
or  the  cold  snare  or  the  high-frequency  electric  cable  may  be  passed 
and  so  applied  as  to  detach  a  suitable  fragment.  It  is  most  important 
to  secure  a  specimen  from  the  edema  and  thickening  which  frequently 
are  at  the  base  of  such  tumors.  The  high-frequency  current  sometimes 
changes  the  specimen  so  that  enough  should  be  secured  to  prevent  tissue 
unaffected  in  this  way. 

Bugbee  has  recently  evolved  another  therapeutic  use  of  the  cysto- 
scope, consisting  in  more  or  less  deep  burning  of  enlargements  of  the 
prostate  with  the  high-freciuency  current.  The  immediate  results  of 
this  method  are  good,  and  the  prospects  of  its  proving  successful  are 
excellent.  If  the  remote  results  are  permanent  it  w'ill  largely  supi)lant 
the  more  dangerous  operation  of  prostatectomy. 

Therapeusis  in  Abnormalities. — As  regards  treatment,  abnormali- 
ties of  the  bladder  in  cystoscopy  consist  chiefly  of  diverticula,  their 

'  Inaug.  Diss.,  Berlin,  1890. 

» Am.  Jour.  Surg.,  1910,  xxiv,  205. 

'  New  York  Med.  Jour.,  1913,  xcvii,  8.57. 

*  An.  d.  mal.  d'org.  genito-urin.,  1891,  ix,  829. 

'  Jour.  Am.  Med.  A-ssn.,  1913,  Ixi,  1857. 


THERAPEUSIS  OF  THE  BLADDER  IN  CYSTOSCOPY        811 

diseases  and  treatment.  The  eliief  disease  is  inflammatory,  with  or 
without  the  deposit  of  ealcuH.  With  the  cystoscope  and  ureteral 
catheters  diverticula  may  be  evacuated,  irrigated  and  medicated  either 
through  instillations  or  direct  applications.  Stones  if  smaller  than  the 
mouth  of  the  diverticulum  may  sometimes  be  dislodged  with  the  aid  of 
the  operation  cystoscope  and  its  accessory  instruments.  Exploration 
of  diverticula  may  be  undertaken  with  ureteral  catheters,  whalebone 
bougies-a-boule  and  the  later  electric  boiigie-a-ljoule  of  Buerger. 

Inspection  of  the  Bladder  Cavity  During  Operation  is  another  field 
of  cystoscopy.  After  the  bladder  is  opened  through  the  suprapubic 
route,  the  cystoscope  may  be  passed  into  the  wound  to  illuminate  the 
cavity  thoroughly  without  reflecting  into  the  operator's  eyes,  as  is  some- 
times inevitable  with  lights  outside  the  body,  or  the  cystoscope  may  be 
passed  through  the  urethra  and  its  light  turned  on  both  to  illuminate 
the  field  and  to  aid  in  carrying  off  blood  and  irrigation  fluid.  The 
immediate  field  of  operation  in  such  a  case  would  have  to  be  away 
from  the  lamp  or  the  neck  of  the  bladder. 


CHAPTER   XV. 

THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS. 

General  Principles. — The  metliod  of  locatiiic:  the  ureters  in  cystoscopy 
in  healtli  and  (Hsease  has  been  cHscussed  in  tlie  section  on  Insj)ectiGn, 
Locahzation  and  Orientation  of  the  BiadckM-.  TJie  most  ini])ortant 
detail  is  tlie  art  of  focussing  the  instrument  upon  the  ureteric  mouth. 
First  the  focus  and  field  of  the  instrument  must  be  familiar  to  the 
0])erator  and  next  he  must  be  dexterous  in  adjusting;  the  instrument  to 
various  positions  with  relation  to  the  mouth.  The  plan  of  findinii;  the 
ureters,  laid  down  in  previous  pages,  produces,  as  a  rule,  a  picture  of 
the  mouths  from  an  angle.  With  the  ureter  in  the  center  of  the  field 
the  instrument  is  rotated  until  the  beak  is  practically  at  right  angles  to 
the  field  and  tlien  by  a])proach  to  or  recession  from  the  object  a  clear 
picture  is  obtained  for  definition,  anatomy,  physiology  and  ])athology. 
It  is  often  necessary  to  move  the  eye-piece  up  and  down  or  from  side  to 
side  in  order  to  succeed. 

THE  NORMAL  URETER. 

Anatomy. — The  number  of  ureters  is  normally  two,  one  from  each 
kidney,  and  their  mouths  are  constricted  by  muscular  fibers  forming  a 
true  sphincter  and  on  the  bladder  floor  the  papilla  of  the  ureter.  The 
mouths  of  the  ureters  are  in  the  ureterotrigonal  or  posterior  inferior 
segment  of  the  bladder  at  the  angles  of  the  trigonum,  usually  in  its 
margin  but  sometimes  within  the  paler  part  of  the  bladder  or  the  highly 
vascular  trigonum  itself.  The  situation  of  the  ureteric  mouths  may  be 
found  where  the  ureteric  folds  merge  into  the  floor  and  interureteric 
bar  as  the  papill*.  Behind  the  folds  and  the  base  is  the  pouch  of  the 
relatively  lower  part  of  the  bladder  floor — the  posterior  superior  seg- 
ment. They  are  usually  separated  by  an  interval  of  one  and  a  half 
to  two  cystoscopic  fields,  that  is,  from  3  to  4  cm.  Occasionally,  how- 
ever, one  or  both  are  so  near  the  middle  line  as  to  bring  both  within  one 
cystoscopic  field,  or  so  far  from  the  middle  line  as  to  emerge  practically 
from  the  side  of  the  bladder  well  above  the  floor.  In  general  appear- 
ance they  are  slits  about  one-eighth  of  an  inch  long,  resembling  the 
infant  vulva,  with  firm  clean-cut  margins  without  exposure  of  the 
mucous  membrane  or  translucency,  both  of  which  indicate  edema. 

The  annexa  in  health  depend  entirely  on  the  exact  location  of  the 
ureteric  mouths  and  they  may  therefore  be  the  trigonum  in  part  or 
whole  or  the  bladder  behind  the  trigonum  in  part  or  whole  with  their 
respective  features.  The  ureteric  and  interureteric  folds  are  properly 
a  portion  of  their  annexa  and  vary  from  considerable  prominence  to 


THE  ABNORMAL  URETER  813 

practical  absence.  Careful  search,  however,  usually  reveals  their 
representatives. 

The  length  of  the  normal  ureter  is  sixteen  inches,  about  40  cm.  The 
caliber  of  the  ureters,  so  far  as  cystoscopic  investigation  is  concerned, 
is  determined  by  the  caliber  of  the  meatal  sphincter  and  varies  from 
4  to  8  F.  in  the  adult  with  material  difference  between  the  sexes. 
Occasional  larger  ureteral  catheters  may  be  used  through  the  modern 
cystoscope.  Undue  stretching  of  the  meatus,  however,  may  tempora- 
rily disturb  the  kidney  function  and  is  not  advisable.  There  are  three 
important  normal  constrictions  in  the  ureter,  namely,  at  the  outlet  of 
the  pelvis,  at  the  point  where  the  ureter  crosses  the  common  iliac 
vessels,  and  at  the  sphincter  in  the  papilla. 

Physiology. — The  normal  ureter  is  manifested  by  contractions  due 
to  the  discharge  of  urine,  which  vary  in  number  and  energy.  Bilateral 
coordination  is  never  present.  Activity  occurs  even  after  a  nephrec- 
tomy when  one  ureter  continues  to  contract  regularly  although  without 
discharge  of  urine,  of  course.  Frequency  of  contraction  is  increased  by 
stimulation  and  by  compensatory  hypertrophy  of  the  healthy  kidney 
in  making  up  the  work  of  a  diseased  fellow.  Frequency  of  the  con- 
traction is  decreased  by  the  reflex  influence  of  nervousness  and  obstruc- 
tion, and  by  the  altered  quantity  and  character  of  the  urine  in  nephritis. 
The  contractions  are  sooner  or  later  commonly  absent  after  nephrec- 
tomy, injury  of  the  kidney  and  ureter  or  both,  and  in  reflex  anuria. 
Persistence  of  contraction  does  not  change  provided  the  reflex  chain  of 
ureterorenospinal  action  is  maintained.  In  these  circumstances  they 
are  practically  unaltered  by  operation,  disease  or  fistulse,  therefore  the 
actual  presence  of  a  urinary  discharge  into  the  bladder  cannot  be  a 
factor  in  the  case.  Where  there  is  no  efflux  of  urine  the  muscular  action 
may  continue,  if  the  nervous  mechanism  is  intact. 

Urinary  Ejaculation  from  the  Normal  Ureter  is,  for  the  sake  of  full 
comparison,  discussed  under  the  same  heading  of  the  abnormal  ureter, 
in  the  following  pages. 

THE  ABNORMAL  URETER. 

Abnormalities  of  the  ureters  are  anatomical  and  pathological. 

Anatomical  Abnormalities. — ^Anatomical  abnormalities  are  those  of 
number,  situation  and  form.  The  normal  number  is  two,  one  leading 
from  each  kidney,  but  there  may  be  two  from  one  kidney  passing  either 
completely  or  partially,  from  kidney  to  bladder.  A  similar  arrange- 
ment as  to  reduplication  may  affect  both  kidneys,  thus  making  four 
complete  or  partially  complete  ureters,  or  tliree  when  there  is  but  one 
ureter  on  one  side.  When  the  supernumerary  ureter  is  pervious  to 
the  kidney  it  is  called  complete,  and  incomplete  when  the  other  con- 
dition obtains.  The  additional  ureters  may  be  near  the  normal,  which 
is  the  common  arrangement,  or  at  a  relatively  great  distance  from  it. 
The  mouth  is  usually  patulous  or  nearly  normal  in  appearance.  The 
discharge  of  urine,  when  the  supernumerary  lu-eter  is  complete,  is 


814  THE  URETERS  AXD  REXAL  FUXCTIOXAL  TESTS 


w 


Fig.  249  Fig.  2.10 

Figs.  24!)  and  2.50. — Author's  case    of    double  risht    ureter.     Fig.  249    is    the    normal 

left   pyelojrrani.     F\>i.  250   shows  double   ureter   and    pelvis,  with  strictured  outlet   of   the 
upper  pelvis. 


Fig.  251.  —  Sharp  kink  in  ureter, 
demonstrated  by  soft  ureteral  bougie. 
Roentgenogram  by  Dr.  L.  T.  Le  Wald. 
(Bugbee.') 


Fig.  252.  —  Diverticulum  of  ureter, 
following  operation  for  ureteral  calculus, 
demonstrated  by  soft  ureteral  catheter, 
which  forms  a  complete  loop  in  the  diver- 
ticulum. Roentgenogram  by  Dr.  L.  T. 
Le  Wald.     (Bugbee.) 


Jour.  Am.  Med.  Assn.,  1917,  pp.  124-1.34. 


THE  ABNORMAL  URETER 


Slf) 


incoordinate  with  its  fellow  of  tlie  same;  side;  and  opposite  side.  KefJu- 
plication  of  the  ureter  may  also  consist  of  two  outlets  from  the  pelvis 
which  unite  into  one  channel  before  the  bladder  is  reached.  Pilcher 
states  that  he  has  found  three  ureteral  openings  all  of  normal  appear- 
ance. All  abnormal  oi)enings  from  the  bladder  should  be  investigated 
with  the  ureterocatheters  and  .r-ray  catheters,  as  a  normal  healthy 
ureter  may  have  an  abnormal  pathologic  superrmmerary. 


Fig.  253.  Soft  ureteral  bougie  en- 
circlina;  ureteral  calculus  lodged  3  cm. 
from  bladder.  Roentgenogram  by  Dr. 
L.  T.  Le  Wald.     (Bugbee.) 


Fig.  254. — Soft  ureteral  bougie  in 
contact  with  calculus  in  pehds  of  peMc 
kidney.  (Thorium  injections  failed  to 
demonstrate  the  lesion.)  Roentgeno- 
gram by  Dr.  L.  T.  Le  Wald.     (Bugbee.) 


Double  ureters  may  lead  respectively  to  healthy  and  pathological 
portions  of  the  same  kidney;  hence  the  importance  of  correct  diagnosis. 
Multiple  ureteral  meatus  are  usually  easy  to  recognize  in  healthy 
bladders  but  difficult  when  the  mucosa  is  altered  by  inflammation  and 
trabeculation. 

Another  means  of  diagnosticating  the  action  of  supernumerary 
ureters  is  by  the  injection  of  dyes  into  the  circulation,  such  as  indigo- 
carmine,  which  do  not  decolorize  in  the  urine,  and  then  studying  their 
effiux  into  the  bladder.  The  use  of  phenolsulphonephthalein  with  its 
collection  through  separate  urethral  catheters,  one  in  each  ureter,  is 
still  more  valuable  in  the  manner  described  later. 


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THE  URETERS  AS D  REXAL  FVXCTIOXAL  TESTS 


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81S  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

Abnormalities  in  the  situation  of  the  ureters  range  from  the  implan- 
tation of  one  into  the  prostatic  urethra  and  the  otlier  into  the  bladder 
and  both  into  the  bladder  so  as  to  be  within  one  cystoscopic  field,  to 
the  separation  of  the  two  openings  from  each  other  and  the  middle  line 
by  the  displacement  of  one  or  both  high  up  on  the  sides  of  the  bladder. 

Abnormalities  in  the  form  of  the  ureters  rest  on  inflammation, 
neoplasm  and  foreign  bodies.  Inflammation,  by  thickening  the  wall  of 
the  ureter  or  the  immediate  annexa,  may  change  the  form  from  a  slit 
to  a  rigid  hole  of  ^■arious  outline,  i)rominence  and  retraction.  Thus  are 
produced  "pin-hole,"  "golf-hole"  and  other  types  of  ureteral  openings. 

Pathological  Ureteral  Meatus. — Pathological  ureteral  meatus  are 
produced  by  inflanunation,  neoplasm  and  foreign  body.  The  inflam- 
matory meatus  shows  hemorrhage,  not  necessarily  macroscopic,  edema, 
prominence  with  distortion,  recession,  rigidity,  patulousness,  eversion, 
cystic  conditions  and  obstruction,  partial  or  complete.  Stricture  of  the 
ureter  from  inflammation,  neoplasm  or  foreign  body  above,  with  secon- 
dary interference  with  the  circulation  and  the  urinary  efflux,  may  show 
many  of  the  foregoing  signs  of  inflammation  because  this  process  is 
really  secondary  to  the  causative  factor. 

Neoplasm  of  or  near  the  ureter  may  cause  the  symptoms  of  injflam- 
mation,  but  is  more  apt  to  produce  prominence  with  distortion,  and 
then  by  compression,  extrinsic  or  intrinsic  of  the  ureter,  the  signs  of 
stricture. 

Foreign  body  of  the  ureter,  especially  if  in  the  lowest  or  vesical 
segment  of  the  canal,  causes  not  only  the  signs  of  stricture,  partial  or 
complete,  but  also  the  signs  of  secondary  inflammation. 

Pathological  forms  of  meatus  comprise  prolapse,  stricture,  divulsion, 
tear,  contracture  and  distortion  and  rigidity.  Prolapse  of  the  ureteral 
meatus  is  chiefly  inflammatory  in  origin  and  is  due  to  thickening,  pro- 
liferation and  protrusion  of  the  mucosa  exactly  as  in  moderate  degrees 
of  rectal  prolapse.  Ureteral  prolapse  may  resemble  the  mouth  of  a 
sinus  with  exuberant  granulations.  The  muscular  band  or  sphincter  of 
the  meatus  changes  the  normal  flat  relation  to  the  bladder  floor  to 
prominence  with  edema  followed  by  dimpling  of  the  center,  infolding 
with  prominence  of  the  periphery  and  increased  congestion  even  to 
cyst-formation,  by  purse-string  action. 

Stricture  of  the  ureter  at  the  verge  of  the  meatus  progressively 
causes  more  and  more  edema  and  cystic  degeneration  of  the  mucosa, 
chiefly  through  circulatory  interference.  Stricture  high  in  the  ureter 
is  apt  to  show  a  patulous  meatus  through  changes  in  the  muscular 
action  and  the  drainage  of  the  urine,  resembling  in  this  detail  stric- 
ture of  the  urethra. 

Lowsley^  out  of  350  specimens,  measured,  found  the  ureteral  orifice 
narrowed  in  8  cases.  This  is  about  2  per  cent,  of  the  entire  number 
and  shows  that  such  narrowing  is  actually  a  rare  condition. 

Ureteral  calculus,  if  recently  expelled,  leaves  a  divulsed  meatus  with 

'  In  a  personal  communication  to  the  author. 


THE  ABNORMAL  URETER  819 

signs  of  tears  much  like  those  in  the  mucosa  after  an  anal  divulsion. 
This  condition  with  the  stone  in  the  bladder  fixes  the  diagnosis.  If  the 
stone  is  below  the  pelvic  brim,  its  pressure  and  the  chronic  inflamma- 
tion of  its  presence  produce  edema,  which  may  or  may  not  obscure 
patulousness. 

Contractures  and  distortions  of  the  ureteral  meatus  are  usually 
found  with  ulcer,  deep  traumatism,  tuberculosis  and  neoplasm.  The 
ulcer,  if  unhealed,  at  once  reveals  itscjlf.  If  healed,  its  scar  or  the  scar 
of  traumatism  suggests  the  origin  of  the  deformity.  Tuberculosis  of 
the  ureter  usually  sets  up  a  condition  known  as  "golf-hole"  ureter,  a 
round  hole  somewhat  depressed  with  more  or  less  inflammation  of  the 
mucosa  and  often  the  presence  of  tubercles  around  it.  Rigidity  of  the 
ureteral  meatus  is  a  very  common  sign  of  tuberculosis.  Neoplasm, 
depending  largely  on  its  situation,  may  determine  almost  any  possible 
effect  on  the  ureteral  outlet. 

Diagnosis. — Pyelonephritis  of  long  standing  is  usually  accompanied 
with  chronic  infection  of  the  ureter  and  therefore  shows  inflammation 
of  the  ureteral  meatus  with  edema,  patulousness  and  much  pus. 

Tuberculosis  of  kidney  and  ureter  is  usually  revealed  by  edema  of 
the  meatus,  indolent  inflammation,  large  or  small  quantities  of  pus,  with 
bleeding  as  a  prominent  symptom,  not  so  much  in  quantity  as  in  con- 
stancy, and  recurrence.  There  is  practically  always  some  blood,  either 
on  microscopic  or  macroscopic  examination.  As  the  disease  infects 
the  lower  zone  of  the  ureter  thickening  and  retraction  of  the  meatus  to 
the  "golf-hole"  type  occurs. 

Hydronephrosis  affects  the  ureter  through  pressure  and  gives  a 
hyperemic,  edematous  meatus.  When  the  ureter  is  closed  there  will  be 
no  urine  only  possibly  mucus  and  pus;  while  it  is  open  the  flow  of  urine, 
containing  mucus  and  pus,  will  be  redundant. 

Stone  in  the  ureter  or  kidney  gives  a  meatus  with  inflammation  of 
more  active  t;\T)e  and  mucus  and  pus  in  slugs  and  strings,  diSicult  to 
detach  with  the  ureteral  catheter  which  is  usually  obstructed.  Partial 
or  complete  obstruction  produces  obvious  change  in  the  quantity  of 
the  efflux. 

Neoplasm  of  the  kidney  and  ureter  is  apt  to  give  great  hyperemia 
of  the  meatus  and  when  bleeding  occurs  it  is  in  gushes  of  rather  large 
quantity. 

Ureteral  disease,  in  brief,  therefore,  is  suggested  by  definite  changes 
in  the  form,  size,  prominence,  patency,  elasticity  and  muscular  action 
and  excretion  of  the  ureters.  Study  of  these  various  and  important 
factors  is  the  first  step  toward  a  diagnosis. 

Pathological  ureteral  evacuation  includes  urine,  mucus,  blood,  pus, 
gravel  and  dyes,  experimentally  injected  for  the  study  of  the  function 
of  the  kidneys  and  their  ureters.  The  normal  efflux  is  included  in  the 
following  description  for  the  sake  of  comparison. 

The  sign  of  ureteral  activity  is  a  relaxation  of  the  ureteral  sphincter 
shown  by  an  opening  by  the  normal  slit  and  followed  by  a  swirl  in  the 
contents  of  the  bladder  which  tends  to  rise  if  the  specific  gravity  of  the 


S20  THE  I'RETERS  A.\D  REXAL  FUXCTIONAL  TESTS 

urine  is  low  or  to  fall  aloiii:  tho  bladder  if  it  is  high.  If  the  meatus  is 
rigid  the  muscular  action  is  not  apparent.  If  the  efflux  is  not  normal 
urine  and  the  bladder  contents  are  clear,  then  as  the  case  may  be,  the 
blood,  pus,  mucus,  flakes,  fat,  phosphates  or  dyes  are  at  once  seen  in 
contrast  as  they  emerge  in  slow  or  ra])id,  large  or  small  discharges. 

The  ureteral  discharge  is  definite  in  its  regularity  and  coincides  with 
the  contraction  of  the  ureter.  It  is  increased  by  those  factors  which 
increase  the  contractions,  and  decreased  by  those  which  decrease  the 
contraction,  such  as  obstructions.  It  is  absent,  us  a  rule,  in  comj)lete 
obstruction  and  after  nephrectomy,  and  also  with  anuria  of  reflex 
origin,  as  jireviously  discussed  under  ])hysiology  of  the  normal  ureter. 

Blood  in  the  urine  discharged  from  the  ureter  may  be  microscopic 
and  is  discovered  only  by  ureteral  catheterization.  Likewise  many  of 
the  other  abnormal  constituents  of  the  urine,  or  the  blood  may  be 
macroscopic  in  (juantity,  appearing  as  jets  or  putt's  floating  across  the 
field  like  the  classic  pictures  of  volcanic  eruption.  Confusion  in  the 
cystoscopy  is  often  cleared  by  using  the  irrigation  cystoscope  or  a 
cystoscope  with  two  ureteral  catheters  in  place  as  the  inflow  and  out- 
flow channels. 

Annexa  of  pathological  ureters  correspond  with  the  diseased  ureter  or 
kidney,  and  thus  are  leads  toward  suggesting  a  diagnosis.  The  fact 
that  the  vault  of  the  empty  bladder  collapses  upon  the  floor  frequently 
leads  to  affections  and  infections  of  it  at  the  point  opposite  the  diseased 
ureter.  This  is  particularly  true  in  tuberculosis  and  is  doubtless  due  to 
washing  of  the  germ-bearing  urme  upon  such  portion  of  the  bladder  as 
it  lies  over  the  diseased  ureter. 

The  annexa  of  ureters  in  pathology  present  every  possible  gradation 
of  congestion,  inflammation,  edema,  rigidity,  prominence,  inelasticity 
and  deformity.  A  very  im])ortant  feature  for  recognition  is  tubercles 
about  a  suspected  ureter,  while  there  are  still  but  two  or  three,  and 
before  they  become  numerous  and  ulcerous. 

Indications. — Indications  of  pathological  ureters  are  always  to  ex- 
})l()re  and  investigate  the  ureter  and  kidney  of  the  aftectcd  side  and  of 
the  normal  side  for  comparison  in  all  accepted  wa>'s,  particidarly 
cystoscopy,  ureteral  meatoscopy,  ureteral  catheterization  without  and 
with  .r-ray  photography,  and  the  functional  renal  tests.  This  series 
of  steps  is  comparable  to  a  thorough  investigation  of  the  ])ulmonary 
system  from  nose  to  lungs  in  suspected  tuberculosis. 

The  foregoing  description  of  the  various  changes  in  the  ureteral 
meatus  is  suggestive  and  not  conclusive  of  diagnosis.  No  experienced 
cystoscopist  would  ever  endeavor  to  reach  a  decision  in  any  case  from 
the  ap])carance  of  the  ureteral  meatus  and  its  annexa  alone.  This  is 
particularly  true  in  the  earlier  degrees  of  disease  precisely  when  modern 
diagnosis  aims  to  be  reliable  and  when  operation  is  most  safe.  Quite  to 
the  contrary  the  skilled  observer  suspends  judgment  until  he  shall 
have  secured  all  possible  data. 

The  ureteral  meatus  shows  signs  of  disease  chiefly  when  the  intra- 
pelvic  segment  of  the  ureter,  namely,  the  distal  third  is  involved.    This 


URETERAL  CATHETERIZATION  821 

is  especially  true  in  the  progressijig  lesions,  such  as  tuberculosis  amonj^ 
inflammations,  neoplasm  and  mi^fratins  stone.  Disease  in  the  supra- 
pelvic segment  or  proximal  two-thirds  of  the  ureter,  (embracing  the 
kidney  and  its  pelvis  also,  often  may,  but  does  not  always,  show  changes 
in  the  ureteral  meatus.  The  uncertainty  of  these  facts  is  another 
reason  for  exhausting  every  detail  of  diagnosis  for  a  conclusion. 

URETERAL  CATHETERIZATION. 

Preliminaries  and  General  Considerations  essentially  include  knowl- 
edge of  the  anatomy,  topography  and  orientation  of  the  bladder  in 
males  and  females,  in  adults  and  children.  Naturally  such  knowledge 
embraces  that  of  the  anatomy  of  the  ureters  and  the  kidneys  and  also 
their  physiology,  as  influenced  by  such  factors  as  nervousness,  fear,  food, 
drink,  drugs  and  disease.  Appreciation  of  the  possibilities  of  damage 
and  accident  to  the  urinary  organs,  during  examination,  must  be  alive 
and  keen.    Skill  with  the  mechanism  and  familiaritv  with  the  electrical 


Fig.  271. — The  bulbous  ureteral  catheter  and  telescope.  One  of  the  author's  set  of 
bulbous  catheters  is  shown  adjusted  to  the  telescope,  with  the  bulb  beyond  the  tip  of  the 
telescope,  so  as  to  be  accommodated  by  the  sheath.  There  is  no  other  way  to  use  or  pass 
these  special  ureteral  catheters.      (Original.) 

parts  of  the  cystoscope  must  be  subconscious  with  the  operator.  No 
operator  may  conscientiously  undertake  these  investigations  in  the 
absence  of  such  training. 

Preparation  of  the  patient  and  bladder  requires  all  forms  of  asepsis 
and  antisepsis  at  the  time  of  the  examination,  internal  medication, 
especially  of  urinary  antiseptics,  and  the  postoperative  irrigation  of 
the  bladder  and  instillation  of  weak  silver  nitrate  solution,  as  pre- 
ventives against  mfection  and  secondary  urethral  chill  and  anuria,  as 
discussed  in  fuller  detail  in  previous  chapters. 

Armamentarium. — In  addition  to  the  ordinary  examining  cystoscope 
and  all  the  accessories  previously  discussed,  there  will  be  required 
the  catheterizing  telescope  and  the  ureteral  catheters  and  stilets. 
The  catheterizing  telescopes  have  already  been  described  in  detail  on 
page  703. 

Choice  of  Ureteral  Catheters. — The  best  forms  of  these  instrmnents 
are  of  French  manufacture  and  have  the  following  features :  The  tips 
are  filiform,  conical,  olivary,  and  most  serviceable,  "flute-end"  with  a 
terminal  and  two-side  openings,  respectively  1  and  2  cm.  from  the  tip 


S22  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 


h         S         f         e 


d 


Fig.  272. — Ureteral  exploring  instruments:  (o)  blunt,  round  tip  renal  catheter  with 
wax  bulb;  (b)  olive  tip  renal  catheter  with  large  wax  bulb  protected  on  either  side  with 
smaller  bulb;  (c)  Cunningham  graduated  whistle  tip  catheter;  (d)  flexible  bougie  (7  mm. 
diameter).  Sizes  vary  from  3  to  10  mm.,  the  smaller  sizes  being  useful  for  dilating 
through  the  cystoscope  from  below,  and  the  larger  sizes  for  retrograde  dilatation  from 
above;  (e)  whalebone  filiform,  varjdng  sizes  are  used  through  the  cystoscope;  (/)  metal 
searcher  with  olive  tip;  {g)  metal  bulb  dilator  3  mm.  with  curved  olive  tip;  (h)  metal 
bulb  dilator  5  mm.  with  curved  olive  tip.     (Hunner.^) 

'  Jour.  Am.  Med.  Assn.,  April  1,  1911,  Ivi,  937  to  941;  Surg.,  Gynec.  and  Obst.,  October, 
1912,  pp.  444  to  457;  ibid.,  May,  1910,  pp.  485  to  493;  Internat.  Clin.,  vol.  iv,  Series  22. 


URETERAL  CATHETERIZATION  823 

and  at  opposite  poles  of  one  diameter.  The  otlier  forms  of  tip  neees- 
sarily  omit  the  terminal  inlet.  Storage  and  sterilization  of  the  eatheter 
are  fully  described  in  the  section  on  Equipment  and  Preparation  for 
Cystoscopy  on  page  711. 

Mensuration  of  the  penetration  of  the  catheters  into  the  ureters  is 
provided  by  color  bands,  each  1  cm.  wide,  and  alternately  black  and 
yellow  or  black  and  red,  begiiming  at  the  tip  and  contiiming  to  the 
funnel  or  cylindrical  end.  Every  5  cm.  special  gilt  bands  are  put  in 
order  to  facilitate  the  correct  measurement,  as  follows :  at  5  cm.  one  gilt 
band,  at  10  cm.,  two,  at  15  cm.,  three,  at  20  cm.,  four,  and  at  25  cm., 
either  five  narrow  or  one  wide  gilt  stripe.  After  this  x^oint  is  reached, 
the  same  system  of  marking  the  next  25  cm.  is  repeated  so  that  the 
30  cm.  point,  for  example,  is  recognized  by  one  narrow  band  proximal 
to  the  operator  beyond  the  wide  stripe  or  the  five  narrow  stripes  of  the 
25  cm.  point. 


Fig.  273. — Author's  set  of  bulbous  catheters.  These  bulbous  catheters  tend  to  prevent 
leakage  of  urine  around  the  catheter  and  thus  to  make  the  quantity  of  urine  collected 
more  accurate.  The  size  of  the  catheters  is  5  to  6  F.  for  the  set  and  the  sizes  of  the  bulbs 
are  stepped  regularly  8,  9,  10,  11  and  12  F. 

It  is  well  to  repeat  here  that  the  normal  ureter  in  the  adult  is  about 
40  cm.  long. 

The  diameter  of  the  ureteral  catheter  varies  from  3  F.  to  8  F.  Hardly 
any  double  catheterizing  cystoscopes  readily  accept  larger  than  two 
7  F.  instruments.  The  operation  cystoscopes,  however,  will  accept  one 
size  7  F.  and  one  8  F.  or  possibly  two  8  F.  The  average  ureter,  on 
account  of  the  normal  narrowings  near  the  bladder,  over  the  iliac 
vessels  and  at  the  renal  pelvis,  permits  complete  passage  of  only  5  F 
or  6  F. 

A'^-ray  ureteral  catheters  are  made,  whose  walls  are  permeated  vrith 
the  salts  of  bismuth,  lead  and  silver.  These  are  not  so  satisfactory, 
however,  as  the  insertion  of  a  stilet  into  the  catheter.  These  stilets  are 
made  of  two  strands  of  piano  wire  twisted  for  flexibility  and  having  an 


824  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

outside  diameter  suitable  for  the  luuieu  of  all  eouunon  sizes  of  catheter. 
Their  fiexihility  is  such  that  they  will  coil  in  bladder,  luvter,  or  kidney 
pelvis,  without  dauiajje  to  the  mucosa. 

Advancement  of  the  Ureteral  Catheter  is  i)rt)cured  by  patience  and 
gentleness  to  a\<iid  si)asni,  i)ain  and  chafing  of  the  nuicosa.  The 
direction  of  the  catheter  shoidd  be  as  nearly  as  possible  in  the  axis  of 
the  ureter,  which  in  axial  vision  cystoscopes  is  securetl  by  carrying  the 
eye-piece  to  the  oi)posite  side  and  u})ward,  each  about  three  niches, 
luitil  the  ureteric  mouth  is  in  the  middle  of  the  field  and  more  or  less  at 
right  angles  to  the  instrument.  The  same  object  is  secured  with  the 
laterovision  cystoscope  by  variations  in  the  positions  of  the  reflector 
and  by  similar  arrangement  of  the  cystoscojie,  making  s])ecial  use  of 
rotation.  The  moment  of  relaxation  of  the  ureter  for  discharge  of  urine 
is  favorable  for  entrance  and  advancement  of  the  catheter,  l\a])id  and 
rough  haiuUing  of  the  catheter  are  not  advisable  and  in  every  case  the 
eye  of  the  operator  should  watch  the  entire  procedure. 


Fig.  274  Fig.  27.', 

Fig.  274. — The  catheter  is  advaneed  toward  and  engages  in  the  meatus,  without  ever 

covering  it  from  \-iew.     (Pasteau  and  Ambard.^) 
Fig.  275. — The  catheter  has  penetrated  the  meatus  and  gently  curves  as  it  is  advanced. 

(Pasteau  and  Ambard.) 

Degree  of  Penetration  of  the  Catheter  is  various.  The  normal  length 
ranges  from  45  cm.  to  40  cm.  as  extremes  and  from  27  to  35  cm.  as  the 
common  limits.  For  simple  diagnosis  of  separate  specimens  of  urine, 
5  cm.  to  10  cm.  penetration  are  enough.  To  establish  the  patency  of 
the  entire  canal,  to  wash  out  the  pelvis  of  the  kidney  and  to  treat  the 
ureter  as  a  whole,  the  catheter  should  be  advanced  into  the  ]Kdvis  of 
the  kidney.  Proof  that  the  pelvis  has  been  entered  is  established  by  the 
loss  of  sensation  of  easy  progress,  by  bending  of  the  catheter  in  the 
bladder  under  the  eye  at  further  attempts  at  advancement,  and  usually 
by  the  steadier  and  less  rhythmic  dripping  of  the  urine. 

1  Encyclopedic  Frangaise  d'Urologie,   1914,  ii,  69. 


URETERAL  CATHETERIZATION  825 

Duration  of  Retention  of  the  Catheter. — Siini)le  cxi)l(>ratic>ri  for 
patency  rccjuircs  no  rctciitioji.  Diagnosis  wliicli  rests  on  individual 
urine  from  each  kichiey  demands  from  one  to  two  honrs;  while  lavage 
and  drainage  of  the  kidney  and  ureter  permit  several  days'  retention, 
very  much  as  is  the  rule  in  corresjxuiding  urethral  conditions. 

Character  of  Urinary  Excretion. — A  few  drops  in  rapid  succession 
at  dehnite  intervals  and  witli  certain  rhythm  mark  the  normal  excre- 
tion of  the  urine,  but  the  two  kidneys  rarely  act  at  the  same  moment. 
Continuotis  arrhythmic  dripping  usually  indicates  that  the  upper 
zone  of  the  ureter  or  the  renal  pelvis  has  been  reached  or  that  there  is 
present  one  of  the  following  conditions:  polyuria,  dilated  ureter, 
hydronephrosis,  pyonephrosis,  calculus  and  reflux  of  the  bladder 
contents  of  the  ureter  when  the  catheter  is  too  near  the  entrance. 
Displacement  of  the  catheter  into  the  bladder  also  gives  continuous 
dripping.  Thus,  it  is  always  necessary  to  investigate  the  source  of 
this  form  of  discharge. 

Absence  of  dripping  of  urine  may  mean  temporary  reflex  anuria  which 
passes  away  in  about  ten  minutes;  the  longer  the  interval,  especially 
about  an  hour,  the  greater  the  likelihood  of  a  pathological  basis. 
Absence  of  dripping  from  a  catheter  which  was  previously  discharging 
indicates  a  plugged  tube  through  mucus,  blood,  pus  or  calcareous 
deposits — best  relieved  by  withdrawing  and  flushing  the  catheter  into 
the  bladder.  Lea'kage  around  the  catheter,  recognized  by  the  swirl  of 
the  urine,  leads  either  to  absence  or  irregularity  of  the  usual  drops 
from  the  catheter. 

Management  During  the  Securing  of  Specimens  respects  the  patient's 
comfort  and  requires  the  electricity  to  be  turned  off  to  prevent  the 
lamp  from  burning  the  mucosa,  the  foot-rest  up,  the  lower  extremities 
down,  a  Wolbarst  or  other  basin  between  the  thighs  as  a  bottle-rest  and 
reservoir  for  leakage,  and  finally  a  support  for  the  cystoscope  if  retained. 

Various  mechanical  devices  for  retaining  the  cystoscope  for  purposes 
of  teaching  and  collection  of  separate  urines  have  been  devised.  Among 
the  best  is  that  of  Friedman.^  On  the  whole  the  author  prefers  no  such 
device,  as  their  rigidity  is  apt  to  cause  pain  to  the  patient  during  slight 
movements,  even  that  of  respiration.  The  cystoscope  had  best  be 
removed  during  the  taking  of  specimens,  of  course  after  the  urologist 
is  satisfied  that  the  catheters  fit  the  ureters  and  that  the  urine  is  not 
leaking  unduly  about  them.  For  teaching  purposes  the  demonstrator 
may  sit  slightly  to  one  side  and  by  steadying  his  forearm  and  hand 
against  the  table  or  the  buttock  of  the  patient  secure  all  the  fixity 
necessary. 

Withdrawal  of  the  Catheters  requires  the  following  details :  slowness, 
gentleness,  preferably  observation  with  the  cystoscope  reintroduced, 
instillation  of  weak  silver  nitrate  solution  into  the  ureter  if  the  likeli- 
hood of  direct  infection  from  the  bladder  is  feared,  study  of  the  molded 
form  of  the  catheter  if  present,  evacuation  and  preservation  of  the 

1  Jour.  Am.  Med.  Assn.,  1914,  Ixii,  453. 


826  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

bladder  contents  for  analysis,  and  finally  the  toilet  of  the  bladder 
itself  with  continuation  of  urinary  antiseptics  by  mouth  for  a  few  days. 

Molding  of  Retained  Catheters  may  suggest  the  form,  direction, 
displacement,  de\iation  or  deformity  of  the  ureters,  through  the 
softening  of  tlie  heat  of  the  body  and  the  normal  pressure  on  it.  It 
is  therefore  of  service,  after  withdrawing  the  catheters,  to  observe 
whether  such  molding  lias  occurred. 

Ureteral  Meatoscopy  without  Ureteral  Catheterism  concerns  both 
tlie  ureters  and  the  kidneys,  but  has  many  limitations  and  uncertainties 
and  cannot  be  relied  on  for  more  than  suggestive  rather  than  final 
diagnosis.  The  diseased  condition  must  aifect  the  mouth  itself,  which 
is,  therefore,  most  connnon  when  the  lower  third  of  the  ureter  is 
involved,  below  the  brim  of  the  true  bony  pehis.  The  commonest  con- 
ditions are  inflammations,  especially  tuberculosis,  calculus  and  tumor 
low  down.  In  the  upper  two-thirds  above  the  brim  of  the  bony  pelvis, 
mere  meatoscopy  is  of  little  value  in  suggesting  tlie  nature  of  the 
disease  of  either  ureter  alone,  kidney  alone,  or  both.  In  long-standing 
disease  of  the  kidney,  with  slow  descent  of  the  process  to  the  region 
of  the  terminal  third  of  the  ureter,  meatoscopy  becomes  more  valuable, 
but  then  only  because  it  may  recognize  the  condition  of  the  ureter. 

For  these  reasons  it  is  best  not  to  rely  on  meatoscopy  but  always  to 
resort  to  catheterization. 

Advantages. — The  advantages  of  ureteral  catheterization  concern 
both  the  ureters  and  the  kidneys. 

Ureteric  Conditions  Diagnosticated  by  Ureteral  Catheterization  become 
most  important  in  disease  of  long  standing,  as  in  health  the  procedure 
is  frequently  not  necessary  and  almost  always  very  simple.  The 
features  elucidated  are  position,  number,  condition,  patency  and  form 
of  the  ureter.  In  all  these  the  catheter  is  an  exploring,  evacuating  and 
verifying  tube. 

The  number  of  ureters  may  be  the  normal  two,  or  abnormal  varia- 
tions on  either  or  both  sides  as  subsequently  explained. 

The  position  of  the  ureters  may  be  normal,  at  each  angle  of  the 
trigonum,  but  either  or  both  may  be  displaced  nearer  or  farther  from 
the  middle  line,  even  to  the  walls  of  the  bladder. 

The  condition  of  the  ureters  may  be  normal  or  the  result  of  inflam- 
matory and  similar  changes. 

The  patency  of  the  ureters  may  be  varied  from  the  normal  5  F.  to 
6  F.  by  constriction  due  to  malformation,  to  pressure  by  external  organs 
such  as  the  uterus  and  prostate,  to  kinks,  to  aberrant  bloodvessels  and 
to  inflammatory  deposits.  Calculi  acting  as  foreign  bodies  may  block 
the  ureters  and  thickening  and  stricture  of  the  wall  may  almost  close 
them.  Dilatation  of  the  ureters  is  looked  for  in  pregnancy,  spinal 
paralyses  affecting  their  muscular  walls — both  giving  relaxed  patulous 
mouths  into  which  very  large  or  even  two  catheters  may  be  passed. 
Dilatation  of  the  ureters  proximal  to  obstruction  is  shown  by  a  steady 
flow  of  the  retained  urine  in  rapid  drops  rather  than  in  periods  of 
dropping. 


URETERAL  CATHETERIZATION  827 

The  form  and  direction  of  the  ureters  may  vary  in  health  and  disease. 
Catheters  frequently  mold  themselves  and  after  withdrawal  will  tem- 
porarily resume  the  shape  of  the  canal  and  thus  assist  in  this  element 
of  diagnosis. 

X-ray  ureteral  catheters,  including  both  the  use  of  the  stilet  and  the 
catheters  impregnated  with  bismuth  and  lead,  are  of  great  value  in 
diagnosis.  Under  this  heading  belongs  the  injection  of  ureters  and  renal 
pelves  with  solutions  impervious  to  the  a;-rays,  such  as  collargolum, 
argyrol  and  the  like. 

Renal  Conditions  Diagnosticated  by  Ureteral  Catheterization  include  the 
various  functional  tests  in  health  and  in  actual  or  supposed  disease. 
Bilateral  specimens  may  be  secured  in  nephritis,  pyuria,  hematuria, 
hydronephrosis,  lithiasis,  neoplasm,  neurosis,  displacement  and  mal- 
formation. 

Dangers  and  Accidents  include  ascending  infection  and  traumatism, 
especially  perforation,  bleeding,  obstruction  and  leakage  prevented  by 
asepsis,  gentleness  and  observation. 

Infection  of  the  ureter  by  catheterization  must  be  very  rare  inasmuch 
as  nearly  all  authorities  who  have  had  large  numbers  of  these  cases 
have  failed  to  report  such  accidents.  The  writer  has,  himself,  never 
encountered  an  example.  Its  prevention  involves  only  clean  instru- 
ments, a  bladder  as  clean  as  possible,  anteoperative  and  postoperative 
administration  of  urinary  antiseptics,  and  if  necessary,  the  instillation 
of  very  mild  antiseptics  into  the  ureter  after  the  catheter  is  withdrawn, 
precisely  as  in  the  urethra. 

Traumatism  and  Perforation  of  the  Ureters  are  avoided  by  patience 
and  gentleness  and  respect  for  the  facts  that  the  ureter  is  delicate  and 
that  disease  may  still  further  weaken  the  tissue.  Delay  may  permit 
a  catheter  to  mold  itself  and  subsequently  pass  along  the  ureter 
previously  seemingly  obstructed. 

Bleeding  During  Ureteral  Catheterism  proceeds  from  breaks  in  the 
varnish  of  the  catheter,  edema,  and  congestion  or  inflammation,  devia- 
tions in  the  course  and  caliber  of  the  canal,  and  the  disturbance  of 
impacted  stone.  The  bleeding  points  may  be  minute  so  that  further 
advance  of  the  catheter  beyond  them  checks  the  blood.  Or  the  bleeding 
may  be  followed  by  more  or  less  cessation  of  the  urinary  output,  which 
proceeds  from  clogging  of  the  eyes  with  clots.  It  is  corrected  best  by 
withdrawing  the  catheter  into  the  bladder  and  under  the  eye,  flushing 
it  clean  and  replacing  it  in  the  ureter.  IMore  active  bleeding  requires 
rest  in  bed,  the  usual  sedatives  and  postponement  of  the  examination. 

Obstruction  to  the  Catheter  in  the  Ureter  proceeds  from  the  following 
causes,  fully  discussed  in  subsequent  pages  on  Pathological  Ureteral 
Sequelae :  small  meatus,  muscular  spasm  of  the  walls  which  is  usually 
overcome  by  waiting,  deviation,  curves  and  kmks  m  the  course  of  the 
ureter,  which  are  sometimes  passed  by  permitting  the  catheter  to  mold 
itself  in  conformity  therewith,  deformity,  distortion  and  stricture  in 
disease  which  are  frequently  impassable,  pressure  from  without  the 
ureter  by  tumors,  aberrant  bloodvessels  and  displaced  viscera  and 


S2S  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

within  the  calil)er  by  impacted  calculi  which  may  he  ciiciiinvented  by 
l^atieiK-e  and  various  trials  with  other  catheters. 

Leakage  Around  the  Catheter  is  very  connnon  but  usually  of  suuill 
amount  and  negligible.  If  eoi)ious  it  mdlifies  the  si)eeimens  collected 
and  shouKl  therefore  always  be  watched  for  during  a  catheterization  of 
the  ureters..  Change  to  a  larger  size  of  catheter  will  correct  it  except 
in  cases  of  dilated,  diseased  canals  in  which  catheterization  is  usually 
a  failure  oil  this  one  account. 

Confusion  of  the  Catheters  from  the  Two  Sides  is  an  error  easily  ])re- 
ventcil  by  one  of  two  })recautions:  The  catheters  may  be  of  different 
sizes,  for  mstance,  5  F.  and  G  F.  or  (i  F.  and  7  F.  They  may  also  be 
selected  with  different  markings,  black  and  red  for  one  side,  black  and 
yellow  for  the  other,  or  the  ")  cm.  subdivisions  nuiy  vary  and  thus  di.s- 
tmguish  them.  The  author  uses  a  very  simple  and  reliable  expedient, 
which  is  to  cut  the  end  of  the  left  catheter  obliquely  and  the  end  of  the 
right  catheter  transversely  across.  Thus  each  side  is  always  disthict 
from  the  other  side. 

Aids. — Aids  in  ureteral  catheterization  include  observation  of  the 
swirl  of  the  urine  and  the  injection  of  dyes  whose  appearance  in  the 
bladder  is  commonly  very  prompt.  Indigocarmine  and  methylene  blue 
are  among  the  most  common.  Turbid  medium  indicates  removal, 
irrigation  of  the  ])ladder  and  renewal.  Constantly  recurrhig  turbidity 
requires  steady  irrigation  through  an  irrigatmg  cystoscope  so  as  to 
wash  the  field  clear  ahead  of  the  objective  and  catheter. 

Technic  with  Axial  Vision. — Cystoscopes. — Introduction  of  the  cysto- 
scope is  fully  (lescril)ed  in  the  section  on  Inspection,  Localization  and 
Orientation  of  the  Bladder  on  page  742.  Any  single  or  double,  direct- 
or indirect- vision  catheterizing  cystoscope  may  be  used,  such  as  have 
been  discussed  in  the  section  on  Perfected  Types  of  Cystoscope  on  page 
704.  The  bilateral  catheterizing  instruments  are  universally  preferred. 
Of  the  axial  vision,  Brown's  and  of  the  lateral  vision,  Buerger's  instru- 
ment will  serve  for  illustration. 

1.  The  mstrument  closed  with  its  obturator  is  passed  into  the  blad- 
der, w^hose  toilet  is  performed  if  possible  previously,  otherwise  through 
the  sheath  of  the  mstrument.  ^Yith  the  bladder  at  least  partially 
dilated,  the  obturator  is  withdrawn,  the  flow  of  dilating  fluid  stopped 
with  the  finger  or  thumb  and  the  catheterizing  telescope,  carrying  the 
ureteral  catheters  with  their  permeability  duly  proved,  with  their 
proximal  ends  plugged  with  pins  or  tooth-picks  and  with  their  point 
of  entrance  through  the  catheter  tubes  tightly  washered,  to  prevent 
leakage,  and  with  their  tips  placed  just  out  of  the  field  of  vision;  in 
other  words,  with  details  in  readiness  and  in  working  adjustment,  is 
inserted. 

2.  The  interureteric  fold  and  margin  of  the  trigonum  and  right 
ureter  are  located  as  described  on  pages  750,  751,  761  and  826. 

3.  ]\Iamtaining  a  good  focus  and  clear  field,  the  instrument  is 
steadied  with  one  hand  resting  either  on  the  table  or  on  the  patient's 
buttock. 


URETERAL  CATHETERIZATION  829 

4.  The  right  catheter  is  now  advaricecl  until  its  rounded  point 
presents  well  across  the  field  for  perhaps  two-thirds  of  the  field  and 
made  to  approach  within  a  short  distance  of  the  ureteric  mouth. 

5.  At  least  half  the  length  of  the  ureteric  mouth  should  be  k('i)t  in 
view  and  the  whole  length  never  obscured  by  the  catheter,  precisely 
as  in  target  practice,  the  sight  never  fully  covers  the  buH's-eye  but  only 
a  small  lower  portion  of  it,  so  that  the  bull's-eye  and  the  rifle  sight  are 
always  distinct  from  each  other. 

6.  With  the  catheter  just  across  the  field  and  presenting  at  the  lower 
half  of  the  ureteric  mouth  the  cystoscope  and  catheter  as  a  unit  are 
manipulated  and  advanced  until  the  tip  of  the  catheter  engages  in  the 
ureter  first  along  the  lower  portion: 

7.  The  cystoscope  is  now  steadied  as  before  and  the  catheter  ad- 
vanced with  the  free  hand  up  to  the  desired  limit  of  penetration  in  the 
ureter,  usually  from  3  to  10  cm. 

8.  With  the  right  ureteral  catheter  in  place  sufficiently  to  avoid  its 
withdrawal  as  the  cystoscope  is  moved  about,  the  instrument  is  made 
to  traverse  along  the  interureteric  bar  and  margin  of  the  trigonum  to 
the  left  ureter,  which  is  catheterized  in  the  same  way.  With  the 
experience  and  knowledge  of  the  right  ureter,  already  gained,  the  left 
is  usually  more  easily  entered. 

Retention  of  the  cystoscope  has  the  following  advantages  with  what- 
ever type  of  instrument  is  employed.  The  light  may  instantly  be 
turned  on  for  recognition  of  difficulties,  the  verification  that  the 
catheters  are  in  good  position,  the  determination  of  leakage  around  the 
catheters,  the  evacuation  of  such  leakage,  if  it  causes  painful  disten- 
tion, and  the  elimination  of  the  likelihood  of  disturbing  the  catheters 
in  the  attempt  to  withdraw  the  cystoscope.  The  disadvantages  of 
this  procedure  are  irritation,  especially  in  sensitive  bladders,  pain  and 
discomfort  from  the  weight  of  the  instrument  even  if  well  supported, 
and  most  important,  a  tendency  to  stimulation  or  inhibition  of  the 
kidney  function,  which  usually  suffers  somewhat  from  the  ureteral 
catheters  themselves,  and  may  accordingly  show  reflex  polyuria  or 
oliguria. 

Withdrawal  of  axial  vision  cystoscopes  and  freeing  the  catheters  is 
probably  the  better  procedure  and  has  the  following  steps : 

1.  Advance  each  catheter,  if  possible,  several  centimeters  into  its 
ureter,  to  allow  for  unavoidable  slipping  in  the  subsequent  manipula- 
tion. 

2.  Turn  off  the  light  so  that  the  whole  instrument  will  be  cold  and 
the  patient  not  made  to  jump  by  the  touch  of  the  hot  lamp. 

3.  Remove  the  caps  or  washers  from  the  catheter  canals  m  the 
telescope,  and  next  slip  them  off  the  catheters  themselves,  both  to 
provide  unimpeded  passage  of  the  catheters  through  the  canal. 

4.  Hold  the  catheters  about  5  cm.  away  from  the  eye-piece  to  pre- 
vent any  pull  from  the  ureters  during  the  next  step. 

5.  Unlock  the  telescope  and  pass  it  backward  to  the  hand  holding 
the  catheters  which  may  then  also  seize  the  eye-piece. 


830  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

6.  The  other  hand  now  disengages  the  catheters  from  the  catheter 
grooves  of  the  telescope  and  pulls  thera  through  the  canals. 

7.  The  same  hand  then  steadies  the  sheath  and  the  catheters  at  the 
meatus  while  the  telescope  is  passed  out  of  the  sheath  and  over  the 
catheters. 

8.  With  the  catheters  in  one  hand  free  from  their  grooves  and 
Ix^tween  the  hub  of  the  instrument  and  the  lamp,  the  other  hand  slowly 
withdraws  the  sheath,  being  careful  not  to  disturb  the  catheters. 

9.  When  the  cystoscope  is  out  the  presence  of  the  catheters  in  the 
ureters  is  shown  by  the  intermittent  dropping  of  the  urine  present 
pre\ious  to  the  manipulation.  If  the  liow  is  in  steady  drops  without 
intermission  from  either  or  both  catheters,  it  is  safe  to  assume  that  they 
have  been  displaced.  If  there  is  the  slightest  doubt,  a  small  obser- 
vation cystoscope  should  be  introduced  for  final  decision. 

Difficulties  with  Axial  Vision  Cystoscopes  \'ary  in  health  and  disease 
and  rest  on  the  fact  that  the  field  is  directly  ahead  of  the  observer  and 
that  the  instrument  must  be  shifted  through  a  wide  radius  in  order  to 
gain  a  view  of  the  upper  and  lower  anterior  segments  of  the  bladder. 

In  health  these  difficulties  rest  on  the  anatomy  of  the  trigonum,  which 
is  usually  flat  but  may  be  markedly  convexed  by  the  prostate  and  uterus 
or  concaA'ed  by  the  vagina  in  women. 

In  perivesical  disease  in  females  cystocele  causes  a  deep  concavity 
of  the  bladder  and  the  application  of  the  vaginal  elevator  to  steady  and 
enter  the  ureters.  Uterine  enlargement  in  menstruation,  pregnancy, 
displacement  and  tumor  makes  the  trigonum  prominent  and  rounded. 
In  males,  generalized  enlargement  of  the  prostate  repeats  this  deformity 
or  a  single  lobe  may  project  over  one  ureter. 

In  intravesical  disease  recent  inflammation  through  swelling  and 
edema  makes  the  ureters  difficult  to  find  except  with  the  aid  of  dyes 
and  the  swirl  of  normal  or  abnormal  urine. 

Old  inflammation  causes  deformity,  distortion  and  contraction,  and 
may  require  dilatation  with  ascending  sizes  of  catheter  reinforced  with 
stilets  or  with  the  ureteral  bougies-a-boule  of  Buerger  before  competent 
catheterization  can  be  accomplished. 

Old  dilated  ureters  may  readily  be  entered  but  the  amount  of  leakage 
around  the  catheters  renders  the  observation  of  these  specimens 
unreliable. 

Technic  with  Laterovision  Cystoscopes. — Introduction  of  the  cysto- 
scope has  the  same  details  as  the  axial  vision  instruments.  The  Buerger 
double  catheterizing  instrument  is  taken  as  the  model  of  this  class.  It 
is  assumed  that  a  previous  exploration  of  the  bladder  has  been  made 
with  the  simple  examination  instrument,  otherwise  this  telescope  may 
be  employed  before  the  catheterizing  telescope  is  introduced. 

1.  The  instrument  occluded  with  the  operator  enters  the  bladder 
previously  prepared;  if  not,  its  toilet  is  performed  through  the  sheath 
of  the  instrument  and  the  bladder  left  dilated.  The  obturator  is  with- 
drawn, loss  of  the  contents  stopped  with  the  thumb  and  the  catheteriz- 
ing telescope  armed  with  its  catheters  tested  for  permeability,  plugged 


URETERAL  CATHETERIZATION  831 

at  their  proximal  ends  and  washered  at  the  canals  to  check  leakage, 
lubricated,  and  placed  with  their  tips  on  the  deflector,  is  passed  seated 
and  locked  in  the  sheath.  Every  mechanical  and  electrical  detail  must 
have  passed  inspection. 

2.  The  air  bubble  is  located  and  the  instrument  rotated  through 
180  degrees,  the  interureteric  fold  and  margin  of  the  trigonum  recog- 
nized, and  by  rotation  of  the  instrument  to  the  left  through  from  40 
to  60  degrees  the  right  ureter  is  located. 

3.  With  correct  focus  and  definite  field  the  instrument  is  adjusted 
and  steadied  with  one  hand  placed  on  the  table  or  patient's  thigh  so 
that  the  ureteric  mouth  is  in  the  upper  part  of  the  field. 

4.  The  right  catheter  is  now  pushed  well  across  the  field  and  directed 
with  the  deflector  until  well  in  the  axis  of  the  ureter. 

5.  About  half  the  length  of  the  ureteric  mouth  should  be  kept  in 
sight  and  never  covered  with  the  catheter  for  the  reason  explained  in 
the  technic  of  the  axial  vision  instrument. 

6.  From  this  position  cystoscope  and  catheter  as  a  unit  are  manipu- 
lated and  advanced  until  the  tip  of  the  catheter  enters. 

7.  The  cystoscope  is  now  rested  in  one  hand  as  before  and  the 
catheter  pushed  onward  with  the  other  hand  to  the  desired  3  cm.  to 
10  cm.  of  penetration.  Lowering  of  the  deflector  often  frees  the  catheter 
and  permits  easier  advance. 

8.  The  experience  and  knowledge  gained  in  placing  the  right  ureteral 
catheter  at  sufficient  depth  to  prevent  displacement,  the  cystoscope  is 
rotated  in  the  opposite  direction  until  the  left  ureter  is  found.  The 
steps  of  entering  it  are  the  same  as  those  for  the  right  side. 

Another  means  of  locating  the  ureters  is  to  withdraw  the  instrument 
until  the  neck  of  the  bladder  appears  at  one  margin  of  the  field,  then 
rotate  it  through  nearly  180  degrees  and  slowly  advance  it  really  along 
the  lateral  border  of  the  trigonum  until  the  ureter  is  found  at  or  near 
the  angle.    Of  the  two,  this  is  the  less  satisfactory  method. 

Withdrawal  of  the  Laterovision  Cystoscope  and  Freeing  the  Catheters 
presents  the  following  details: 

Steps  one,  two  and  three  are  the  same  as  in  this  procedure  with  the 
axial  vision  instrument. 

The  next  step  is  to  remove  the  cystoscope,  remembering  that  its 
beak  is  downward.  This  may  be  done  in  two  ways:  The  eye-piece 
may  be  depressed  in  the  middle  line  of  the  body  five  or  six  inches  and 
then  with  the  reverse  steps  of  withdrawing  a  sound,  removed  from  the 
bladder  and  urethra,  following  at  their  proper  moment  and  manner 
steps  four,  five,  six,  seven,  eight  and  nine  described  for  the  axial  vision 
instrument. 

Or  the  proceeding  may  be  as  follows:  The  foregoing  depression  is 
made  and  then  the  eye-piece  of  the  instrument  is  carried  laterally  until 
against  one  of  the  patient's  thighs.  These  two  motions  pass  the  beak 
first  above  both,  then  over  and  to  the  side  of  one  ureteral  catheter. 
The  eye-piece  is  now  elevated  in  the  plane  of  the  patient's  thigh  for 
five  or  six  inches  and  then  carried  over  to  the  middle  line.     These 


832  THE  URETERS  AXD  REXAL  FUNCTIONAL  TESTS 

two  motions  pass  the  beak  under  the  (^le  and  finally  between  the  two 
catheters.  From  this  position  it  is  withdrawn  by  the  same  steps  as 
stated  above.  rememberin<i;  that  this  second  technic  crosses  the 
catheters  one  above  the  other.  If,  however,  the  catheters  of  different 
sizes  and  of  different  inarkin<i:s  have  been  used,  no  inconvenience  or 
error  will  ensue. 

Technic  with  Urethracystoscopic  Tubes. — Special  instruments  for 
Ki'Hn  's  uiH'tcral  catlutcrisni  tubes  include  a  set  of  tlilating  instru- 
ments or  the  Kelly  urethral  dilator,  a  set  of  tubes  and  obturators, 
several  catheters  and  syringes  for  evacuating  the  urine,  Kelly's  bladder 
forceps  for  swabbing  the  mucous  membrane,  probes  for  recognizing 
the  ureters,  and  finally,  a  stock  of  ureteral  catheters. 

Introduction  of  the  Instrument. — Kelly's  cystoscopic  tube  was  the 
original  t^pe  and  is  taken  as  the  example  for  the  technic  of  all  other 
tubes  such  as  Pryor's,  Cullen's,  and  Luys'.  Kelly's  illumination  is  by 
reffected  light  from  a  head  mirror  while  others  use  an  electric  lamp 
placed  near  the  objective  end.  The  steps  of  the  examination  are  as 
follows,  including  the  usual  preliminaries  described  for  the  other 
instruments: 

1 .  Empty  the  bladder  with  a  soft -rubber  catheter. 

2.  Anesthetize  the  bladder  with  2  per  cent,  alypin  solution  and  the 
urethra  with  crystals  of  alypin,  cocain,  novocain  or  eucain. 

3.  Dilatation  of  .the  urethra  is  usually  required  with  bougies-a-boule, 
straight  sounds  or  the  conical  dilator  of  Kelly  in  order  to  accept  the 
largest  tube  reasonably  possible. 

4.  Sym's,  the  genufacial,  or  Trendelenburg's  posture  is  preferred. 
The  last  has  the  advantage  of  causing  the  abdominal  contents  to 
gravitate  away  from  the  bladder  and  permit  more  ready  entrance  and 
examination  of  it.  In  fleshy  patients,  when  possible,  the  genufacial 
position  relieves  the  bladder  best. 

5.  Passage  of  the  largest  tube  possible  \\ith()ut  tramnatism  is  easy 
with  the  obturator  in  place  and  guided  by  the  finger  when  required. 

6.  Withdrawal  of  the  obturator  is  followed  by  the  outlet  of  urine  in 
the  bladder  and  the  inlet  of  air  from  the  dilatation. 

7.  Illumination  is  now  turned  on  and  the  bladder  cavity  ex])l()rcd 
in  exactly  the  same  manner  as  with  any  other  direct-vision  instrument, 
including  the  detail  of  search  for  the  ureters. 

8.  Residual  urine,  if  present,  is  pumped  out  with  catheter  and 
syringe  or  wiped  away  with  the  swabs  on  the  vesical  forceps. 

9.  Passage  of  the  ureteral  catheter  requires  dryness  and  cleanliness 
of  the  field,  presence  of  the  ureter  at  the  objective  end,  pressure  of  the 
tube  against  the  mucosa  to  aid  in  keeping  out  urine  from  the  other 
ureter,  gentle  passage  of  the  catheter  to  the  desired  depth,  followed  by 
search  and  catheterism  of  the  opposite  ureter  by  exactly  the  same 
steps. 

Withdrawal  of  the  Kelly  Tube  is  performed  hi  much  the  same  manner 
as  the  same  detail  with  the  other  instruments  and  the  collection  of  the 
separate  specimens  is  similarly  managed.    Errors  with  the  Kelly  tube 


URETER  A  L  CA  TJJETERJZA  TJON 


833 


are  chiefly  due  to  the  similarity  between  the  ureters  and  other  depres- 
sions of  the  mucosa.     Distinction  is  obtained  by  exploration   with 
probes  before  the  catheters  are  passed. 
Advantages  of  Kelly  Tubes  are : 

1.  The  field  may  be  kept  dry  and  not  infected  from  the  rest  of  the 
bladder  for  the  passage  of  the  catheter. 

2.  The  presence  and  condition  of  botli  kidneys  may  be  quickly 
recognized  as  with  any  other  cystoscope. 

3.  Ureteric  conditions  of  any  type  may  be  explored  with  facility. 

4.  Catheters  retained  in  the  ureters  serve  as  landmarks  during 
extensive  pelvic  operations  and  thus  prevent  flamage  of  the  ureters. 

Technic  with  the  Braasch  and  Eisner  Cystoscopes. — As  previously 
described  these  instruments  are  virtually  modified  tubes  and  axial 
vision  instruments. 


Fig.  276 


Fig.  277 


Fig.  278 


Fig.  279 


Fig.  280 


Fig.  281 
Figs.  276-281. — Graduated  ureteral  catheters.  Fig.  276,  ball-pointed  exploring 
instrument.  Fig.  277,  round-pointed,  double  eye,  Pasteau  catheter  with  centimeter 
graduations,  but  without  five  centimeter  graduations.  Figs.  278,  279  and  280,  respec- 
tively, the  round-,  whistle-  and  olive-pointed  Albarran  catheters  with  double  eyes  and 
centimeter  and  five-centimeter  graduations.  Fig.  281,  catheter  of  Albarran  -n-ith 
shoulder  three  centimeters  from  the  tip. 

General  preliminaries  and  introduction  of  the  mstrument  are  the 
same  as  with  all  other  cystoscopes  just  described  with  the  following 
additions : 

1.  The  obturator  is  withdrawn  and  the  air-tight  window  sealed. 

2.  Toilet  of  the  bladder  if  not  previously  performed  requires  inflation 
with  water  and  in  and  out  irrigation,  the  supply  tube  being  attached 
to  the  stop-cock  and  the  outflow  occurring  through  the  catheter  tubes 
provided  with  short  rubber  tubing,  permitting  shutting  off  of  the 
outflow  by  pinching  them  against  the  eye-piece. 

3.  Exploratory  cystoscopy  and  search  for  the  ureters  follow  in  the 
same  manner  as  for  the  axial  vision  instruments. 

53 


834  THE  URETERS  AXD  REX. XL  FUNCTIONAL  TESTS 

4.  Dilatation  is  maintained  with  air  or  water.  Air  is  not  without 
danger  of  absorption  and  eniboHsni  asprovefl  by  case  reports  in  litera- 
ture. AVater  is  preferred  to  air  and  according  to  Hraasch  should  be 
under  slight  continuous  flow  during  the  operation. 

5.  After  the  ureter  is  located,  the  catheter  sterilized  is  brought  to  the 
operator  with  sterile  instruments  and  engaged  in  its  canal  in  the  same 
way,  next  advanced  along  the  canal  o^•er  the  field  of  vision  and  into  the 
ureter.  Sim])le  diagnosis  recjuires  a  ])cnctration  of  10  cm.  while  full 
exploration  of  ureter  and  kidiu-y  pchis  demands  tiic  full  achance  of 
the  catheter. 

Choice  of  Instruments. — Choice  of  instruments  for  ureteral  cath- 
eteri/atio]i  is  ])racticall\'  the  sanu>  as  for  ordinary  cystosco])y.  The 
begijmer  shoukl  be  so  skiUul  w  ith  the  axial  ^■ision  and  the  laterovision 
cystoscope  of  a  type  with  wliicli  he  is  familiar,  that  the  purchase  of 
many  instruments  is  muiecessary  and  ill-advised.  For  this  reason  the 
axial  vision  instrument  of  Brown  or  one  of  its  modifications  and  the 
latcrovisit)!!  instruments  of  Buerger,  or  one  of  its  foreign  equivalents 
are  all  the  required  set  for  a  very  large  number  of  average  cases.  Other 
instruments  may  be  purchased  as  need  may  arise. 

PATHOLOGICAL  URETERAL  SEQUEL.E. 

Varieties  of  Pathological  Ureteral  Sequels. — (  ertain  ureteral  conditions 
of  great  im])()rtance  have  definite  subjective  and  objective  symptoms 
like  diseases,  although  not  diseases  but  only  pathological  secjuels.  The 
most  significant  are  stricture,  obstruction,  dilatation,  wounds  and 
fistulse. 

URETERAL  STRICTURE. 

Varieties  include  anatomical  and  ])ath()l()gical  Aarieties.  Anatomic- 
ally the  ureter  shows  normal  narrowings  at  the  renopelvic  outlet,  the 
iliac  vessels  and  the  bladder  wall.  Pathological  constriction  is  most 
common  at  the  meatus  but  like  urethral  stricture  may  present  at  any 
point.  The  degree  of  closure  varies  from  moderate  to  tight ,  but  is  rarely 
complete,  and  the  varieties  of  the  lesion  are  dilatable  or  soft  and  rigid 
or  hard. 

Etiology. — The  causes  of  ureteral  stricture,  like  those  of  urethral 
stricture,  are  intrinsic  and  extrinsic,  both  within  and  without  the 
ureter,  and  are  es.sentially  inflammatory  from  underlying  infection, 
traumatism  and  foreign  body. 

Pathology. — The  pathology  of  ureteral  stricture  resembles  the  results 
of  infiannnation  in  all  mucous  membranes  and  presents,  therefore, 
inflammation,  infiltration,  scar  and  contracture.  Alterations  in  the 
caliber  of  the  canal  afl'ect  the  ureter  above  and  below  the  stricture, 
resulting  in  dilatation  above  and  atony  below  with  more  or  less  inter- 
mittent or  chronic  discharge  of  mucus,  pus  and  blood,  in  strings  and 
shreds,  exactly  as  in  urethral  stricture. 

Sequels. — The  sequels  of  ureteral  stricture  in  the  bladder  occur  only 
when  it  is  near  or  at  the  meatus  and  aflect  the  floor  with  congestion, 


URETERAL  OBSTRUCTION  AND  DILATATION  835 

edema  and  cysts.  In  the  ureter  the  results  above  are  flilatation  with 
later  atony,  and  below  altered  activity  with  atony.  Both  involve  more 
or  less  chronic  inflammation.  In  the  kidney  the  outcome  is  at  first 
dilatation  of  the  pelvis,  then  hydronephrosis,  and  finally  y)yeloneph- 
ritis.  A  partial  stricture  rendered  sudrlenly  comj)l(!te  causes  cessation 
of  renal  function.  On  the  affected  side  the  foregoing  changes  occur 
while  on  the  normal  side  compensatory  hypertrophy  and  overactivity 
of  the  kidney  occur. 

Diagnosis. — ITreteral  stricture  is  suggested  by  subjective  pain  and 
discomfort  varying  with  the  lesion  in  situation,  degree  and  constancy. 
Proof  of  ureteral  stricture  rests  on  reduction  in  the  size  of  the  catheter 
passable  or  in  absolute  impermeability  to  these  instruments,  and  on 
the  pain,  blood  and  discharge  related  with  exploration. 

Treatment. — Ureteral  stricture  has  indications  along  the  same  lines 
as  those  of  mechanical  and  inflammatory  ureteral  obstruction  and 
dilatation  and  lithic  ureteral  obstruction,  and  is  accordingly  discussed 
under  these  headings. 


URETERAL  OBSTRUCTION  AND  DILATATION. 

Causes. — Obstruction  and  its  sequel,  dilatation  of  the  ureter,  are 
considered  together  for  the  reason  that  the  latter  hardly  ever  occurs 
without  the  former.  It  might  be  well  to  consider  these  subjects  with 
stricture,  were  it  not  for  the  fact  that  obstruction  may  exist  without 
stricture  of  the  ureter  itself. 

The  common  factors  of  ureteral  obstruction  and  dilatation  are  in 
situation,  urethral,  prostatic,  vesical,  uterine,  vascular,  inflammatory, 
lithic  and  paralytic. 

Mechanical  Ureteral  Obstruction  and  Dilatation. — Varieties  and 
Clinical  Features.  —  Urethral  stricture,  prostatic  h^^e^trophy,  and 
vesical  neoplasm  simply  by  the  hydraulics  of  back  pressure  of  urine 
impeded  in  outlet,  set  up  progressively,  hj'pertrophy,  dilatation  and 
chronic  inflammation  of  the  ureter.  The  urinary  discharge  is  strong 
as  long  as  the  muscular  coat  is  healthy,  and  weak  w^hen  the  stage  of 
atony  appears. 

Pressure  of  the  gravid  uterus  acts  directly  on  the  ureter  as  it  does  on 
veins  and  induces  obstruction.  The  urinary  discharge  is  feeble  in  the 
marked  cases  only.  Its  frequency  is  normal,  as  there  is  no  alteration  in 
the  nervous  or  muscular  mechanism. 

The  sequel  is  hydronephrosis,  and  later,  with  infection,  pyelitis. 
The  diagnosis  is  by  catheterization  which  usually  evacuates  a  copious 
steady  flow  of  urine  in  drops  like  a  hydronephrosis,  normal  and  clear, 
unless  pyelitis  has  supervened. 

Aberrant  renal  and  lumbar  arteries  may  cross  and  constrict  the 
ureter,  resulting  in  the  vascular  forms  of  ureteral  obstruction.  The 
degree  is  usually  moderate  and  the  symptoms  slight.  The  diagnosis 
rests  on  a  dilatable  evenly  passable  obstruction  with  little  discomfort 


836  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

to  tlie  jxitient  and  witli  marked  relief  of  dilatation  of  the  renal  pelvis 
if  present  through  the  steady  rapid  dropping  of  the  urine. 

Treatment. — ]Mechanical  ureteral  obstruction  and  dilatation  demand 
first,  the  removal  of  the  cause,  and  second,  the  relief  of  the  lesion  in 
the  ureter  if  persistent,  after  the  cause  has  been  remedied.  The  steps 
of  this  procedure  are  the  same  as  those  discussed  under  treatment  of 
lithic  ureteral  obstruction. 

Inflammatory  Ureteral  Obstruction  and  Dilatation. — Location. — 
Inflanunatory  ureteral  obstruction  may  be  located  within  and  with- 
out the  canal  at  any  point.  The  infrapelvic  segment  of  the  ureter 
is  more  or  less  associated  with  lesions  of  the  bladder  about  the 
meatus  while  the  suprapelvic  or  upper  two-thirds  of  the  ureter  may  be 
diseased  with  little  or  no  efl'ect  on  the  bladder.  Tuberculosis  causes 
multiple  constrictions,  dilatations,  ulcerations  and  similar  lesions  in 
the  ureter  as  elsewhere,  and  is  the  commonest  source  of  inflammatory 
obstruction.  Foreign  bodies,  namely,  calculi,  are  identified  with  stric- 
ture and  dilatation,  and  are  considered  under  the  subsequent  heading 
of  lithic  obstruction. 

The  exudate  varies  with  the  degree  of  inflammation.  The  commonest 
organisms  are  Bacillus  tuberculosis  and  Bacillus  coli  communis. 

Ureteral  catheterism  and  all  its  modern  adjuvants  are  often  required 
for  final  diagnosis. 

Lithic  Ureteral  Obstruction  and  Dilatation. — Varieties  and  signifi- 
cance of  lithic  ureteral  obstruction  are  formative,  migratory  and 
impacted.  The  significance  of  stone  in  the  ureter  is  the  fact  and 
degree  of  the  obstruction  and  the  effect  on  the  ureter  at,  above  and 
below  the  point  of  impaction  and  on  the  kidney. 

Cause. — Formative  or  native  ureteral  calculi  are  the  product  of  chronic 
inflammation  associated  with  other  sources  of  obstruction,  but  are 
relatively  much  less  frequent  than  the  other  two  forms. 

Migratory  ureteral  calculi  are  of  renal  and  pelvic  origin.  Small 
stones  of  this  class  pass  throughout  the  ureter  into  the  bladder  with 
few  but  severe  sjTnptoms  of  colic.  Their  arrest  is  temporary  at  one 
of  the  normal  constrictions  of  the  ureter.  Occasionally  they  are 
returned  into  the  pelvis  of  the  kidney  from  the  narrowing  just  distal  to 
it,  but  more  commonly  they  slowly  descend  into  the  bladder  where  the 
cystoscopist  may  discover  them,  or  are  evacuated  with  the  urine.  Thus, 
such  stones  are  not  very  commonly  under  cystoscopic  examination. 

Impacted  ureteral  calculi  are  capable  of  no  further  descent  bej'ond 
their  point  of  fixation.  By  far  the  most  numerous  are  arrested  migra- 
tory stones  from  the  kidney  and  pelvis  above,  while  a  few  are  formative, 
due  to  local  ureteral  disease.  About  30  per  cent,  of  these  stones  are 
impacted  in  the  proximal  third  of  the  ureter,  just  distal  to  the  pelvis, 
about  15  per  cent,  in  the  middle  third,  just  proximal  to  the  brim  of  the 
bony  pelvis  in  the  region  of  the  common  iliac  vessels,  while  55  per  cent, 
are  in  the  distal  or  vesical  third  of  the  ureter,  especiallj^  in  the  region 
of  the  outlet  where  the  ureter  pierces  the  bladder. 


URETERAL  OBSTRUCTION  AND  DILATATION  837 

Chemical  Composition  of  Calculi. — Ureteral  obstruction  is  the  same  in 
the  concretions  and  compositions  as  those  found  in  vesical  and  ureteral 
calculi,  namely,  uric  acid  and  oxalates  in  most  primary  cases,  phos- 
phates in  the  majority  of  secondary  cases.  Compound  stones  are 
found  in  which  a  uric  acid  nucleus,  after  infection,  receives  a  deposit 
of  phosphates  of  the  pelvis  with  decomposition  of  urine. 

Uric  acid  calculi  occur  in  acid  urine,  often  associated  with  uric  acid 
and  urate  crystals.  They  are  commonly  brown  with  red  or  yellow  tone. 
They  are  somewhat  apt  to  be  small  and  faceted  because  multiple,  hard 
rather  than  soft,  ovoid  or  spheroid,  rough  and  irritating.  They  com- 
monly form  the  centers  of  compound  stone  with  phosphates  and  other 
secondary  deposits  upon  them.  They  are  the  most  common  stones  in 
so-called  primary  nephrolithiasis. 

Oxalate  of  lime  stones  also  occur  in  acid  urine,  are  brown  or  blackish, 
darker  than  the  uric  acid  calculi,  very  rough,  hardly  ever  smooth,  con- 
stituting the  so-called  mulberry  calculus.  The  urine  commonly  con- 
tains oxalate  crystals.  Oxalate  stones  appear  in  secondary  cases  as  a 
rule. 

Cystin  stones  are  very  rare  and  occur  only  in  acid  urine. 

Phosphatic  stones  are  the  rule  in  alkaline  urine,  less  so  in  acid  urine, 
are  commonly  white,  spheroid,  larger  than  the  others  because  more 
rapidly  formed,  rough  but  less  so  than  the  oxalates.  The  urine  is  very 
full  of  phosphatic  detritus. 

Sequels. — Sequels  of  lithic  ureteral  obstruction  arise  from  the  partial 
or  complete  closure  of  the  canal,  and  affect  the  ureter  and  the  kidneys. 

On  the  ureter  the  conditions  at  the  seat  of  the  stone  are  chronic 
inflammation,  irritation  and  ulceration  with  their  essential  accompani- 
ments of  mucus,  pus  and  blood.  The  proximal  ureter  is  dilated  at 
first,  hypertrophied,  later  atonied,  while  the  distal  portion  is  congested 
and  like  the  whole  ureter  the  seat  of  inflammation. 

In  the  kidney  of  the  same  side  partial  obstruction  results  in  altered 
function,  dilated  pelvis  and  hydronephrosis.  Later  infection  progresses 
and  produces  pyonephrosis.  Nephritis  usually  precedent  to,  is  aug- 
mented by  the  stone  and  its  obstruction.  Complete  obstruction 
causes  anuria,  on  the  affected  side,  and  sometimes  in  both  kidneys,  of 
severe  and  even  fatal  type. 

In  the  kidney  of  the  opposite  side,  partial  obstruction,  especially  if 
progressive,  results  in  compensatory  hypertrophy,  so  that  this  one 
kidney  may  be  doing  more  and  more  and  finally  all  the  urinary  excre- 
tion. Sudden  complete  obstruction,  as  just  stated,  means  anuria  and 
thereafter  rapidly  developed  compensation. 

Diagnosis.^ — ^Lithic  ureteral  obstruction  is  finally  determined  only 
on  the  basis  of  history,  urinalysis,  physical  examination,  cystoscopy, 
ureteral  catheterization  and  x-ray  investigation. 

The  subjective  history  of  ureteral  stone  is  commonly  of  recurrent 
attacks,  at  first  slight,  and  later  of  slowly  progressing  intensity,  or  of 
sharp,  intense  attacks  referred  to  the  thighs  and  genitals,  especially 
testes.    Dull,  heavy  and  indefinite  discomfort  may  precede  the  attacks 


838  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

for  long  periods  or  alone  be  present.  Stones  in  the  vesical  i)ortion  of  the 
ureter  usually  cause  severe  pollakiuria  and  symptoms  of  cystitis. 
Nausea,  shock,  chills,  fever  and  prostration  accompany  extreme  cases. 

I  rinalysis  is  usually  not  very  satisfactt)ry.  It  may  vary  from  normal 
hyperacid  urine,  Avith  little  or  no  signs  of  renal  or  ureteral  disease,  to 
aciil  or  alkaline  urine,  with  the  signs  of  pyonephrosis,  hydronephrosis, 
nephritis,  ureteritis  and  the  like. 

Urinary  function  is  afi'ected  little  or  much  according  to  the  severity 
and  the  suddenness  of  the  obstruction.  Inunediatc  absolute  obstruc- 
tion causes  anuria  on  the  affected  or  both  sides.  Slow,  recurrent 
obstruction  sets  up  decreasing  function  on  the  affected,  and  increasing 
excretion  on  the  opposite  side.  The  total  output  is  usually  normal  even 
when  one  kidney  has  finally  ])assed  out  of  use.  Hydronephrosis,  while 
closed,  may  or  may  not  change  the  quantity  of  the  in-ine,  according 
to  the  validity  of  the  normal  kidney;  while  being  relieved  there  is  more 
or  less  sudden  and  free  outflow  of  the  urui^.  Infection  and  other 
changes  in  the  various  uruiary  organs  accompanying  the  stone  and  its 
obstruction,  give  characteristic  urinary  conditions. 

Physical  examhiation  iji  lithic  ureteral  obstruction  usually  elicits 
tenderness,  pain  and  mcreased  pus  and  other  urinary  sediments.  It 
shoidd  include  abdominal  exploration  along  the  course  of  the  ureter 
and  bimanual,  rectal  or  vaginal  examination.  The  former  avails  above 
the  brim  of  the  bony  pehis,  and  the  latter  below  it,  so  that  frequently 
stones,  at  or  near  the  bladder  wall,  may  be  felt  and  even  delivered  into 
the  bladder  by  these  manipulations. 

Cystoscopy. — Diagnosis  of  lithic  ureteral  obstruction  usually  reveals 
no  cystitis  unless  the  bladder  has  become  secondarily  involved,  and 
no  material  alteration  of  the  meatus  if  the  stone  is  in  the  proximal 
two-thirds  of  the  ureter.  If  the  stone  and  its  obstruction  are  near  the 
meatus  in  the  vesical  third,  its  pressure  excites  hyperemia,  edema  and 
enlargement,  and  its  consequent  inflammation  produces  mucus,  pus 
and  blood. 

In  the  upper  and  middle  thirds  of  the  ureters,  at  the  renal  pelvis,  and 
above  the  bony  pelvic  brim,  ureteral  stone  causes  very  few  vesical  signs 
and  none  whatever  on  which  diagnosis  may  be  based.  The  urine  is 
discharged  in  small,  frequent  spurts,  past  the  ball-valve  action  of  the 
stone.    Less  than  half  the  stones  of  the  ureter  are  in  these  regions. 

In  the  lower  vesical  third,  however,  the  picture  of  the  ureteric  mouth 
is  one  of  prolapse  by  inflammation  and  edema,  cystic  degeneration  by 
pressure  and  irregularity  and  masking  of  the  lips.  Hemorrhagic  spots 
and  edema  are  common  in  the  annexa.  Acute  cases  show  these  con- 
ditions which  subside  with  the  chronic  cases  to  patulous  deformed  and 
contractured  mouths  and  mucopurulent  stringy  discharge.  The  inter- 
ureteric  fold  and  the  ureteric  folds  are  prominent,  thick,  inflamed  and 
sometimes  edematous  in  the  acute  cases  and  prominent  and  thickened 
in  chronic  cases. 

Lithic  ureteral  obstruction  m  the  \'esical  segment,  that  is,  within  or 
near  the  bladder  wall,  causes,  in  acute  cases,  submucous  ecchymosis, 


URETERAL  OBSTRUCTION  AND  DILATATION  839 

extensive  prominent  edema,  masked  prolapsed  meatus  and  similar 
changes  in  the  ureteric  and  interureteric  folds.  Mucus,  blood  and  pus 
are  discharged  with  the  urine  usually.  Jn  chronic  cases  the  meatus  is 
deformed,  contractured  and  patent  and  ejects  stringy  discharge.  Jf 
the  stone  presents  it  appears  as  a  rounded  or  conical  brown  to  gray 
button  in  the  meatus.  Such  a  cystoscopic  picture,  combined  with 
severe  paroxysms  of  pain  and  pollakiuria,  is  strongly  diagnostic  of 
stone  near  the  outlet  of  the  ureter. 

Lithic  obstruction  of  the  ureter  during  progressive  descent  of  the 
stone  gives  the  same  variations  in  the  picture  as  just  described  for 
impaction  in  various  points,  but  not  with  sufficient  reliability  for  a 
fixed  diagnosis. 

Ureteral  Catheterization.  —  The  diagnosis  of  ureteral  obstruction 
should  include  the  use  of  conical,  olivary  and  fiute-end  standard 
ureteral  catheters  with  or  without  stylets,  bismuth  and  lead  .r-ray 
catheters,  wax-tipped  catheters  of  Kelly  and  the  wax-tipped  whalebone 
filiform  guides  of  Harris.  The  stone  commonly  arrests  the  catheter 
or  permits  it  to  slide  by  with  sudden  jump.  Pain  and  slight  bleed- 
ing are  common  through  disturbance  of  the  stone  in  its  bed.  If  the 
catheter  passes  and  remains  unblocked  by  mucus  and  pus,  a  more  or 
less  copious  evacuation  of  urine  from  the  dilated  ureter  and  pelvis 
above  follows. 

Radiography . — Lithic  ureteral  obstruction  demands  careful  repeated 
photographs  in  all  cases  of  doubt  or  seemingly  negative  results.  No 
photograph  is  conclusive  unless  the  shadow  of  the  stone  overlies  or  is  in 
close  relation  to  that  of  a  styleted  or  a  bismuth  or  lead  a;-ray  catheter, 
or  corresponds  with  the  lower  point  of  the  dilatation  of  pelvis  and  ureter 
above  the  stone  revealed  by  filling  these  portions  with  50  per  cent, 
argyrol  solution  or  collargol.  Errors  arise  from  phleboliths  and  some- 
times changes  in  lymphatic  glands  near  the  ureters,  particularly  below 
the  bony  pelvic  brim.  A  precaution  is  free  evacuation  of  the  bowels 
whose  contents  may  give  deceptive  shadows. 

Treatment. — ^Lithic  ureteral  obstruction  is  approached  through 
intravesical  and  extra  vesical  routes.  The  extra  vesical  methods  are  the 
major  operations  which  should  be  further  mentioned  here.  The  intra- 
vesical details  include  local  anesthesia  of  the  ureter  and  free  lubrication 
by  the  injection  of  sterilized  olive  oil  above  and  below  the  stone,  as  a 
stimulant  of  peristalsis  and  an  aid  of  descent.  Through  the  operation 
cystoscope  the  ureter  should  be  dilated  with  ureteral  catheters,  filiform- 
tipped  dilators  or  Buerger's  ureteral  bougies-a-boule  with  or  without 
the  passage  of  the  d'Arsonval  electrical  current  as  a  prelimmary  of 
either  the  foregoing  or  the  following  steps.  After  widening  the  canal  the 
stone  may  be  delivered  with  the  aid  of  vesical  forceps,  such  as  Buerger's, 
through  the  operation  cystoscope,  the  direct-vision  instruments,  and  in 
women  the  endoscopic  tubes.  The  Buerger  cystourethroscope  might 
be  available  in  rare  cases.  Occasionally  stones  may  be  delivered  by 
massage  through  the  vagina  and  rectiun. 


840  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

URETERAL  WOUNDS  AND  FISTULffi. 

Occurrence. — Ireteral  wounds  occur  chiefly  as  rupture  during  violent 
injury  of  the  kidney  and  punctured  and  incised  wounds  completely  or 
incompletely  dividing  the  canal.  Fistulit  of  the  ureter  results  from 
such  inciilents  most  connnonly,  and  less  frequently  from  sloughing  after 
severe  infection,  pressure  or  traiuna  or  other  interference  with  nutrition. 
Most  traiuna  occurs  in  men  and  in  the  proximal  two-tliirds  of  the 
ureter,  associated  with  renal  injury,  while  operative  accidents  are 
more  frecjuent  in  women  and  below  the  pelvic  brim  where  the  ureter 
is  in  relation  with  the  internal  sexual  organs. 

Diagnosis. — Ireteral  wounds  are  recognized  at  the  time  of  operation 
for  injury  of  the  kidney,  or  of  operation  for  other  purposes.  In  both 
cases  by  the  appearance  of  uruie  in  the  field  in  the  region  of  the  ureter. 
FistulcV  of  the  ureter  are  determined  by  a  history  of  extensive  inter- 
vention for  cancer,  tubal  and  uteruie  disease,  followed  by  incessant 
discharge  of  urine  beginnuig  during  the  first  few  hours  after  the  oper- 
ation or  several  days  later,  if  gangrene  has  been  an  element.  Diagnosis 
of  the  fistulous  outlet  rests  on  the  point  of  its  discharge — abdominal, 
vaginal,  uterine,  intestinal  or  rectal.  Constant  leakage  from  the 
urethra  may  mean  temporary  paresis  or  permanent  paralysis  of  that 
canal  and  not  damage  to  the  ureters.  Dyes,  such  as  indigocarmme  and 
methylene  blue,  injected  into  the  circulation  will  show  on  the  dressing 
in  a  few  moments,  namely,  high  or  low  in  the  vagina,  according  to  the 
point  of  outlet,  or  on  any  other  surgical  dressing  wherever  placed.  If 
this  test  is  watched,  the  dressmg  may  be  removed  and  the  discharge 
of  dye  seen  at  the  mouth  of  the  fistula  before  its  annexa  are  stained, 
and  thus  hide  the  exact  point. 

Cystoscopy  will,  in  recent  cases  with  partial  division  of  the  ureter  only, 
reveal  little  change  or  only  a  reddening  of  the  meatus  and  annexa  in 
wounds  of  low  situation.  Complete  division  of  the  ureter  may  or  may 
not  show  cessation  of  muscular  action,  precisely  as  in  some  cases  of 
nephrectomy  when  the  nerve  supply  of  the  ureter  has  not  been 
damaged.  S'^o  urine  escapes  from  such  cases  while  much  or  little  flows 
when  the  division  is  incomplete. 

Ureteral  catheterism  is  hazardous  in  recent  cases,  especially  of  sus- 
pected rupture,  and  is  rarely  done  excepting  with  the  greatest  gentle- 
ness and  caution.  In  older  cases  the  catheter  will  be  obstructed  by 
infiltration  about  the  point  of  injury. 

Treatment. — Wounds  of  the  ureter  during  operation  may  often  be 
primarily  sutured,  or  if  this  is  impossible,  the  proximal  end  may  be 
implanted  into  the  summit  of  the  bladder.  A  fistulous  tract  may  often 
be  made  to  heal  by  applications  to  its  mouth,  especially  if  the  opening 
is  very  near  the  bladder  into  the  vagina.  The  kidney  in  old  fistulse  is 
often  infected  and  indicates  nephrectomy.  Preventives  of  infection  of 
the  kidney  are  the  regular  use  of  antiseptics,  internally  for  the  urine, 
and  externally  for  the  outlet  of  the  fistula  in  the  vagina  or  on  the  skin. 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS 


841 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS. 

Importance  of  Determination  of  Renal  Function. — The  knowledge 
gained  from  functional  renal  tests  is  the  basis  of  all  surgical  interven- 
tion and  of  selection  of  cases  in  such  a  manner  as  to  make  operative 
statistics  much  more  reliable,  judicial  and  fair.  Unless  the  study  of 
the  renal  reserve  force  shows  that  one  kidney  is  reasonably  capable  of 
carrying  on  the  body  function,  its  diseased  fellow  cannot  be  wisely 
interfered  with  in  material  degree. 


Fig.  282. — Posterior  surface  of  the  kidneys.     (Poirier  and  Charpy.) 


The  object,  therefore,  of  functional  kidney  tests  is  to  indicate  the 
degree  of  destruction  of  the  kidney  function  on  the  diseased,  or  rela- 
tively diseased  side,  as  compared  with  the  capacity  of  the  kidney  on 
the  normal  or  relatively  normal  side. 

Older  methods  of  renal  investigation  are  chiefly  embodied  in  urin- 
alysis, physical,  chemical,  microscopical  and  bacteriological,  with  little 
distinctive  acciu-acy,  however,  because  the  urines  from  both  kidneys 
are  mixed  in  the  bladder,  and  disease  of  the  bladder  and  uretlira 
directly  and  commonly,  and  disease  of  the  prostate,  uterus  and  vagina 
indirectly  and  less  commonly,  confuse  the  deductions. 

Polyuria  of  reflex  origin  increases  the  quantity  and  transparency  of 
the  urine  but  decreases  the  specific  gravity,  color,  percentage  of  m'ea 


842 


THE  URETERS  AXD  REXAL  FUNCTIONAL  TESTS 


and  of  other  important  salts  and  proportionally  tlu>  microscopic 
elements. 

Keflex  oliguria  reverses  all  these  conditions  anil  thus,  also,  is  a  source 
of  error. 

I'rea  determination  alone  may  not  be  relied  on  because  its  percentage 
varies  in  health  with  diet,  exercise  and  other  factors.  Even  with 
ureteral  catheterism  it  is  uncertain  because  leakage  around  the  catheter 
is  a  serious  difficulty  and  indicates  the  necessity  of  always  using  full 
size  catheters. 

L'rinary  salts  other  than  urea,  such  as  the  chlorides  and  phosphates, 
vary  with  diet,  exercise,  nervous  and  other  states,  and  are  in  themselves 
not  very  stable  chemically,  and  hence  cannot  be  relied  on  as  indices  of 
renal  i)ower. 


Fig.  28.3. — Relation  of  the  kidney  to  the  vertebral  column,  rilis,  mii.sclcs,  and  luinho- 
costal  ligaments.     (Poirier  and  Charpy.) 


Albumin  content  of  the  urine  has  important  varieties  from  other 
than  the  kidney  sources,  such  as  the  prostate.  Such  a  factor  must  first 
of  all  be  determined.  The  overstrained  normal  kidney  doing  the  duty 
of  its  failing  or  failed  fellow,  may  have  the  albuminuria  of  congestion 
and  intoxication,  which  disappears  after  the  diseased  kidney  with  its 
toxic  effects  is  removed.  Albuminuria  also  varies  with  diet,  exercise, 
all  toxic  and  absorptive  states,  and  therefore  does  not  finally  denote 
renal,  especially  surgical  renal  lesions. 


FUNCTIONAL  CAPACITY  OF  TIIF  KIDNKYH 


84.3 


Microscopic,  especially  epithelial,  elements  in  the  urine  vary  dnrinj^ 
the  exacerbations  of  chronic  renal  conditions,  and  ap[)car  to  h(i  due 
largely  to  congestion  of  the  better  kidney.  Pilchcr  has  determined  this 
by  actual  ureteral  catheterism  to  the  degree  that  sediment  of  renal 
epithelia  somewhat  resembles  pus  in  the  test-glass.  Such  increased 
microscopical  findings  disappear  after  a  nephrectomy. 


SUPCRIO 
MESENTERIC 
ARTERY 


INFERIOR 

MESENTERIC 

ARTERY 


COMMON 

ILIAC  ARTERY 

AND  VEIN 


INFERIOR    PHRENIC 
ARTERIES 


7  hi  I M        CCELIAC 
ARTERY 


INTERNAL 
SPERMATIC 
ARTERY 
m       AtlD  VEIN 
INTERNAL 
-  ILIAC   ARTERY 
AND   U^IETER 


Fig.  284. — -Posterior  abdominal  wall,  after  removal  of  the  peritoneum,  showing  kidneys, 
suprarenal  capsules,  and  great  vessels.     (Corning.) 


It  will  readily  be  noted  that  all  the  foregoing  established  means  of 
investigating  the  kidneys  have  their  value  but  are  not  final  in  their 
results,  being  really  contributory  and  corroborative  evidence. 

Ureteral  catheterism  has  with  absolute  finality  shown  the  difference 
between  the  urines  in  the  bladder  and  from  the  individual  kidneys. 
Vesical  urine  is  necessarily  affected  by  disease  there,  whereas  the  urine 


844 


THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 


tJiroiigli  the  ureteral  catheter  is  affected  chiefly  in  ciuautity  by  leakage 
and  reflex  polyuria  or  oliguria — all  more  or  less  surmountable  diffi- 
culties, as  compared  with  the  masking  of  the  observation  through 
urine  from  a  cystitis  as  well  as  a  renal  lesion. 

Urethroscopy  is  valuable  for  clearing  up  tlie  source  of  pus  and  blood, 
for  examples,  in  cases  where  the  u])])er  urinary  tract  is  shown  to  be 
free  of  disease. 


SUPERIOR 
tXTREMITY 


CUT  SURFA 
OF   KION 


INFERIOR 
EXTREMITY 


Fig.  285. — The  right  kidney  with  the  pelvis  of  the  ureter  exposed,  and  showing  dorsal 
branch  of  the  renal  artery,  viewed  from  behind.      (Spalteholz.) 


Advanced  Functional  Renal  Diagnosis  includes  the  following  methods 
in  ascending  order  of  merit  in  the  present  state  of  knowledge :  urinary 
conductivity  to  electrical  current,  cryoscopy  of  blood  and  urine, 
chromocystoscopy,  artificial  polyuria,  artificial  glycosuria  and  phenol- 
sulphonephthalein  excretion.  Other  than  the  last  test,  observations 
as  to  the  excretion  of  other  substances  have  been  made  but  discarded  as 
misleading,  examples  are  among  drugs,  salicylic  acid  and  iodid  of 
potash,  and  among  dyestuffs  methylene  blue  and  fuchsin.  Full 
reliance  may  be  placed  on  experimental  glycosuria,  the  phenolsulpho- 
nephthalein  test  or  chromocystoscopy,  if  interpreted  in  the  light  of 
the  older  methods,  stated  in  the  first  part  of  this  chapter. 

Essential  Data  of  Renal  Function  include  the  following  facts:  that  as 
already  pointed  out,  each  kidney  functionates  independently  of  its 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS 


845 


fellow  in  time,  rapidity  and  frequency  of  action  and  in  the  exact  quality 
of  the  urine;  also,  that  there  may  be  great  disease  and  even  destruction 
of  a  small  portion  of  one  kidney  without  impairment  of  its  total  func- 
tion; and  finally,  that  the  results  of  each  and  all  the  foregoing  five 


Fig.  286. — Palpation  of  the  kidney.  Position  of  the  hands  in  Guyon's  method.  (Legueu.) 

methods  give  corroborative  and  valuable  data  for  diagnosis  in  advanced 
disease  of  the  kidney,  but  confusing  and  contradicatory  data  in  slight 
degrees  of  renal  lesion.    This  is  due  to  the  slight  variations  in  the  tests 


Fig.  287. — Palpation  of  the  kidney.     Attitude  of  patient  and  position  and  action  of 
hands  in  Israel's  method.     (Legueu.) 

themselves  and  to  the  excretion  of  the  elements  of  the  various  tests  by 
different  parts  of  the  kidney  substance.  .The  greatest  variation  seems 
to  occur  between  artificial  glycosuria  and  the  dye  tests.  For  example, 
sugar  may  appear  from  both  kidney's  in  twenty  minutes,  the  established 


846  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

normal  standard,  but  a  il>  o  like  indigocarmine  may  be  much  delayed 
in  excretion.  Such  a  circumstance  may  well  be  due  to  the  fact  that 
dirt'erent  parts  of  the  kidney  excrete  chemicals  so  diverse  as  indigo- 
carmine  and  phloridzin. 

Urinary  electrical  conductivity  requires  expensive,  delicate  apparatus 
and  difficult  tcchnic,  but  after  all,  ])ossesses  the  same  ])hysical  basis 
as  specific  gravity  detcnuination.  It  therefore  shows  no  advantages 
and  is  N-cr\'  little  used. 

Cryoscopy  of  Blood  and  Urine. — Advantages  and  Disadvantages. — 
The  advocates  of  cryoscopy  admit  that  it  requires  corroboration  with 
other  means  as  a  rule.  Its  physical  basis  is  that  of  specific  gravity  and 
is  closely  analogous  thereto.  Alone  it  has  no  great  advantages  over 
later  and  more  exact  tests. 

It  owes  its  developments  chiefly  to  European  observers.  Casper 
reports  that  urine  of  low  specific  gra\'ity,  hence  of  decreased  concen- 
tration, occurs  in  kidney  disease  which  is  indicated  by  a  low  cryoscopic 
index.  Rupel  corroborated  this  and  showed  that  the  greater  the  disease 
of  the  kidney  the  lower  the  cryoscopic  index  of  the  urine.  Kapsammer, 
noting  that  polyuria  occurs  in  the  healthier  kidney  and  oliguria  in  the 
diseased  organ,  both  of  reflex  origin,  found  the  freezing-point  of  the 
polyuric  urine  lower  than  that  of  the  oliguric  specimen,  and  thus  he 
established  a  comparative  test  for  the  two  kidneys. 

The  tendency  now  seems  to  be  to  combine  and  compare  cryoscopy 
of  the  blood  and  the  urine  in  each  ]iatient.  Kiunmell,  for  example, 
says  that  if  the  cryoscopic  index  of  the  blood  is  more  than  — 0.()0°  (., 
kidney  insufficiency  is  established  and  nephrectomy  hazardous.  Kor- 
anyi  has  shown  that  the  normal  hemic  cryoscopic  index  with  healthy 
kidneys  is  — O.ofi  °  C.  The  limits  of  variation  in  health  is  only  — 0.01  °  C. 
Hence  it  follows  that  functional  disease  of  the  kidney  is  indicated  when 
the  cryoscopic  index  of  the  blood  is  less  than  — 0.56°  (.,  using  distilled 
water  as  the  standard. 

Principles. — Essential  cryoscopy  of  blood  and  m-ine  as  in  all  other 
fimctional  tests  requires  knowledge  of  the  quantity  of  the  urine  during 
a  definite  ])eri()d  and  of  the  presence  of  nervous  and  other  interfering 
elements,  and  judgment,  foresight  and  reason  in  appl>'ing  the  results 
of  the  tests.  In  a  nervous  patient  a  polyuria  during  a  half-hour,  for 
example,  200  c.c.  with  a  consequent  low  cryoscopic  index,  or  an  oliguria, 
of  say,  20  c.c,  during  a  half-hour,  with  a  consequent  high  cryoscopic 
index,  would  both  be  misleading  and  luifair  bases  for  estimating  the 
functional  activity  and  reserve  of  the  kidneys. 

Apparatus. — The  apparatus  of  cryoscopy  of  blood  and  urine  consists 
of  a  flat-liottom  cylindrical  glass  jar,  filled  with  the  freezing  mixture  and 
resting  on  the  usual  chemical  laboratory  standard.  Within  this  is  a 
similar  much  smaller  Hat-bottom  glass  cylinder  passed  dce])ly  into  the 
freezing  mixture  and  secured  in  place  by  one  of  the  brackets  of  the 
standard.  A  third  and  smaller  similar  glass  tube  fits  inside  of  this  and 
is  held  in  position  in  the  same  manner  and  so  as  to  leave  an  air  space 
between  them.  A  Beckmann  thermometer  with  small  fractional  gradua- 


FUNCTIONAL  CAPACirY  OF  THE  KIDNEYS  847 

tions  is  passed  through  a  cork  in  the  innermost  cyb'nrler  and  supported 
by  a  bracket  of  the  standard  so  that  the  bulb  of  the  thermometer  does 
not  touch  any  part  of  the  apparatus,  otherwise  error  will  result.  A 
platinum  wire  also  passes  through  the  cork  as  a  means  of  stirring  the 
contents  under  observation.  Unless  the  stirring  is  carefully  and 
regularly  done,  the  observation  will  be  worthless. 

Technic. — Cryoscopy  of  the  blood  and  urine  is  founded  on  com})arison 
between  the  freezing-points  of  distilled  water,  blood  and  uriiK,-. 

The  freezing-poijit  of  distilled  water  is  therefore  first  determined  as 
control  and  comparison,  during  constant  gentle  stirring  as  stated,  and 
by  the  following  steps:  The  temperature  falls  promptly  below  the 
freezing-point,  momentarily  rests,  promptly  rises  to  a  higher  point 
where  it  again  briefly  rests,  and  then  recedes  to  the  freezing-point  of 
the  mixture  in  the  outside  cylinder.  The  graduation  reached  by  the 
rise  is  read  off  and  recorded  as  the  freezing-point  of  the  distilled 
water. 

After  this  control  observation  of  the  distilled  water,  the  test-tube  is 
emptied  and  the  blood  and  urine  poured  into  it  in  turn.  The  freezing- 
point  of  each  is  thereafter  determined  in  exactly  the  same  manner. 

In  illustration,  if,  owing  to  circumstances,  the  freezing-point  of  dis- 
tilled water  is  4.03°  C,  and  the  freezing-point  of  blood  is  3.45°  C,  the 
cryoscopic  index  of  the  blood  is  the  difference  between  these  readings, 
namely  — 0.58°  C,  or  two  points  below  the  normal  cryoscopic  index  of 
the  blood — 0.56°  C.  Such  a  result  would  indicate  renal  disturbance 
or  insufficiency  in  virtue  of  Koranyi's  observation  that  in  health  the 
variation  is  only  as  little  as  — 0.01°  C. 

The  freezing-pomt  of  the  urine  varies  from  — 0.9°  C.  to  — 2.9°  C, 
according  to  concentration  or  specific  gravity,  again  using  distilled 
water  as  the  standard  of  the  cryoscopic  index.  Kummell  claims  that 
less  than  — 0.9°  C.  shows  diseased  or  insufficient  kidneys. 

Sources  of  Error. — Deductions  from  cryoscopy  of  blood  and  urine 
are  affected  by  renal  lithiasis  both  impacted  and  migratory,  especially 
in  the  latter  during  colic,  and  by  pressure  of  abdominal  tiunors  and 
pregnancy.  Anemia  and  prostration  even  without  renal  disease  may 
raise  the  cryoscopic  index  several  pomts,  even  to  — 0.53  °  C.  A  lowered 
hemic  cryoscopic  index,  especially  to  the  limit  of  — 0.60°  C,  regarded 
as  the  extreme,  indicates  renal  insufficiency  estimated  m  its  degree  by 
the  amount  of  change  below  the  normal  index  — 0.56°  C. 

Artificial  Polyuria.—  Physical  Basis. — This  test  was  originated  and 
chiefly  developed  by  Albarran,  who  was  associated  with  and  followed 
by  other  European  observers.  Albarran  found  that  the  drmkmg  of  a 
large  amount  of  water  increased  the  quantity  of  the  urine  and  changed 
the  quality,  both  over  a  short  period  of  time.  The  actual  work  thrown 
upon  the  kidneys  is  therefore  increased  and  the  normal  or  less  diseased 
kidney  meets  this  emergency  while  the  more  diseased  or  destroyed 
kidney  fails  more  or  less  fully.  In  other  words,  the  normal  kidney  pos- 
sesses reserve  force  of  rather  wide  limits  so  that  it  may  accommodate 
itself  to  the  increased  fluid  and  the  consequent  strain.    ^Manifestly  if 


848  THE  URETERS  AND  RENAL  FUNCTJOXAL  TESTS 

both  kidneys  arc  diseased,  tlie  response  to  the  test  is  no  jiolynria,  or 
too  little  to  he  reliable. 

Albarran^  and  Guyon-'  ha\'c  pro\ed  that  the  diseased  kidney  has  in 
most  circumstances  a  constant  output  of  water  and  urea,  while  the 
normal  kidne>'  shows  the  usual  ^■ariations  due  to  diet,  water  drinkinfi;, 
exercise  and  the  like,  and  hence  a  ca])acity  of  res])onse  to  the  ])olyuria 
test. 

Essential  Elements. — Functional  renal  capacity  in  the  polyuric  test 
takes  specimens  of  in*ine  excreted  in  definite  periods  of  time,  observa- 
tions are  made  as  to  the  amount  of  the  urine,  the  ])ercentagc  of  urea  or 
its  total,  total  -iiitrogen  output,  sodium  chlorid  content,  cryoscopic 
mdex,  artificial  glycosuria  and  microscopic  elements. 

The  more  copious  the  polyuria  the  greater  will  be  the  changes  in  the 
percentages  without  necessarily  changes  in  the  totals.  The  tendency  is, 
therefore,  to  make  these  observations  in  terms  of  the  total  output  of 
each  kidney. 

Technic. — During  experimental  polyuria  bodily  and  renal  rest  are 
secured  by  having  the  patient  in  bed  and  withdra^^•ing  food  and  drink 
for  several  hours  ])revious  to  the  test.  The  ])atient  is  then  given  500 
c.c.  of  mineral  or  plaui  water  at  one  drinking,  if  possible,  otherwise  at 
several  at  very  close  intervals.  The  bladder  having  been  previously 
prepared  for  cystoscopy,  the  ureters  are  catheterized  and  then  counting 
from  the  time  when  the  500  c.c.  of  water  have  been  taken,  three  speci- 
mens of  urhie  from  each  kidney  are  secured,  namely,  one  each  at  the 
end  of  the  first,  second  and  third  half-hour.  All  these  specimens  are 
examuied  for  the  foregoing  elements. 

The  polxiiria  or  quantity  curve  of  the  lu'ine  varies  between  the 
healthy  and  the  diseased  kidneys,  as  already  pointed  out.  The  normal 
kidney  increases  its  output,  as  a  rule  beginning  with  the  end  of  the  first 
half-hour,  contuiues  the  mcrement  rather  regularly  during  the  second 
and  third  periods,  reaching  the  maximimi  in  the  third  half-hour,  and 
then  a  decrease  sets  in  during  the  fourth  half-hour,  when  the  starting- 
point  is  usually'  reached.  The  percentage  of  urea  usually  falls  pro])or- 
tionally  with  the  degree  of  the  polyuria  while  the  total  quantity  of  iu"ea 
or  of  nitrogen  may  remain  constant  or  even  increase.  The  cryoscopic 
index  also  approaches  the  freezing-point  of  distilled  water  jiroportionally 
with  the  polyuria  and  similarly  the  relative  munber  of  microscopic 
elements  changed. 

The  diseased  kidney  shows  little  change  in  the  various  elements  of 
the  determination  and  no  real  curve  of  polyuria,  both  the  quantity  of 
the  urine  and  the  percentage  of  the  urea  remaining  constant  as  a  rule, 
thus  indicating  that  the  kidney  is  already  working  up  to  its  limit  and 
can  assume  no  more  burden. 

'  Congri^s  Internat.  de  Madrid,  1903  (according  to  the  transactions  this  paper  was 
never  handed  in);  Ann.  des  Maladies  des  Organes  Genitourinaires,  1903,  xxi,  1741;  also 
Exploration  des  Fonctions  R6nales,  Paris,  1905  (Chapter  XII  discusses  experimental 
polyuria). 

2  Assn.  fran^aise  d'urol.,  October,  1897. 


FUNCTIONAL  CAPACITY  OF  TIIK  KIDNEYS  849 

Comparative  charts  of  these  facts  were  prepared  by  Keyes,  who  has 
proved  that  normal  kidneys  in  the  same  individual  show  similar  and 
parallel  curves  and  values  of  efficiency,  and  that  these  indices  may 
vary  from  the  first  determination  at  a  second  examination  hut  always 
more  or  less  in  parallel  degrees. 

Charts  comparing  normal  and  diseased  kidneys  show  a  more  or  less 
constant  unchanging  curve  for  the  affected  side  but  a  wide  curve  for 
the  normal  side. 

Results  and  Deductions. — From  experimental  polyuria  it  therefore 
follows  that  when  the  percentage  of  urea  and  similar  elements  varies 
little  or  increases  for  either  or  both  kidneys,  the  test  is  negative  and 
unsatisfactory.  Leakage  around  the  ureteral  catheters  is  important 
and  may  be  provided  for  by  using  the  largest  size  of  instrument  accept- 
able and  those  with  open  ends  in  preference  to  conical  or  olivary  tips. 
Albarran  has  suggested  injecting  methylene  blue  through  the  catheter 
to  prove  the  presence  or  absence  of  leakage. 

Reflex  polyuria  and  oliguria  are  a  source  of  uncertainty  in  the  test, 
the  former  leading  to  increased  urine  and  decreased  percentage  of  urea 
as  a  rule,  and  the  latter,  to  the  reverse  states.  Occasionally  the 
quantity  of  urine  remains  the  same  and  the  urea  is  increased.  These 
facts  render  corroboration  by  other  tests  necessary. 

Maximum  polyuria  is  reached  during  the  third  half-hour  and  is 
therefore  the  best  period  of  observation,  yet  it  is  well  to  examine  all 
three  specimens  in  order  to  show  the  regularity  of  increase  in  the 
various  details  tln-ough  the  three  half-hour  intervals.  As  stated,  the 
normal  kidney  takes  up  its  added  burden  regularly.  The  diseased 
kidney,  on  the  other  hand,  shows  little  or  irregular  or  no  increase  in 
urine,  and  an  unchanged  percentage  in  the  urea  and  other  elements. 

Bilateral  renal  lesions  bring  in  another  factor  of  uncertainty  and 
require  study  of  the  case  through  other  means  for  elucidation. 

Advantages  and  Disadvantages. — The  advantages  of  artificial  polyuria 
are  that  the  investigation  of  the  several  urinary  contents  permits 
contemporaneous  correlation  and  comparison  thereof,  chiefly  the 
quantity  of  urine,  the  percentage  of  urea,  total  lu-ea  and  nitrogen, 
glycosuria,  cryoscopic  index,  and  estimates,  in  short,  the  reserve  force 
of  the  kidneys  under  the  polyuria  test. 

The  disadvantages  of  this  test  are  its  duration  through  one  and  a 
half  hours  in  wearying  the  patient  and  the  frequency  with  which  reflex 
polyuria  and  oliguria  and  bilateral  disease  renders  the  interpretation  of 
the  findings  most  difficult. 

Temporary  Artificial  Glycosuria. — Physical  Basis. — The  phloridzm 
test  has  proved  that  the  intramuscular  or  subcutaneous  injection 
of  the  glycosid  phloridzin  produces  a  temporary  glycosuria  whose 
measure  in  time  of  appearance  and  in  degree  of  excretion  is  the  basis 
of  the  test.  It  is  not  known  whether  the  glucosid  is  excreted  by  the 
tubules  or  glomeruli  of  the  kidney  and  thus  the  test  is  of  no  value  in 
distinguishing  the  variety  of  nephritis  present.  A  small  dose  only  is 
administered,  in  order  not  to  risk  irritation  of  the  kidney.  Separation 
54 


850  THE  URETERS  AXD  REXAL  FUXCTIONAL  TESTS 

of  the  urine  from  tin-  two  ki(iiu\\s  hy  ureteral  eatheterisni  is  an  essential 
detail  of  the  test. 

Kapsammer's'  method  regards  the  time  of  apj)earance  of  the  sugar 
in  the  urine  and  is  based  on  the  fact  that  diseased  kidneys  delay  the 
excretion  at  least  a  half-hour.     This  test  is  therefore  only  ((ualitative. 

Casper's-  method  prefers  the  quantitative  determination  of  the 
excretion  of  sugar  in  a  d'efinite  period  of  time  and  recognizes  the  fact 
that  diseased  kidneys  excrete  much  less  than  normal  ones  in  the  same 
lapse  of  time.  By  taking  si)ecimens  every  five  minutes  and  subjecting 
them  to  quantitati\c  analysis,  both  Ka])sanimer's  and  Casper's  methods 
may  be  combined  in  mutual  corroboration. 

Technic. — The  phloridzin  test  requires  a  sterile  1  per  cent,  solution 
of  the  glucosid  in  distilled  water  and  is  preferred  to  an  alcoholic  solution 
by  most  observers.  One  granune  of  i)hlori(l/,in  is  dissoh'cd  in  lOO  c.c.  of 
distilled  water,  so  that  1  c.c.  of  the  solution  will  administer  0.01  gramme 
of  the  glucosid,  regarded  as  the  standard  dose.  A  smaller  proportional 
quantity  may  be  prepared  if  desired.  Sterilization  is  secured  by  using 
freshly  distilled  water  and  by  bringing  the  solution  to  a  boil  but  never 
to  active  boiling,  and  loss  of  the  phloridzin  in  the  syringe  is  provided 
for  by  administering  the  solution  warm,  as  precipitation  and  adhesion 
to  the  glass  occur  on  cooling.  The  1  c.c.  graduated  hypodermic 
syringe  of  the  author  is  very  serviceable  for  this  purpose  inasmuch  as 
it  permits  fractional  doses  in  tenths  if  elected. 

Kapsanivier's  Phloridzin  Technic. — The  drug  is  injected,  the  ureters 
catheterized,  separate  specimens  are  taken,  and  at  the  end  of  ten 
minutes  a  qualitative  analysis  for  sugar  is  made.  Separate  specimens 
are  taken  thereafter  every  five  minutes,  ending,  as  a  rule,  with  thirty 
minutes,  and  thus  making  a  total  of  five  specimens.  Each  is  analyzed 
for  sugar.  Negative  results  during  the  first  half-hour  require  continu- 
ation during  a  second  half-hour. 

Normal  kidneys  usually  begin  to  excrete  sugar  in  from  ten  to  fifteen 
minutes  but  may  exceptionally  delay  for  thirty  minutes. 

Diseased  kidneys  are,  as  a  rule,  ^'ery  much  slower  than  these  limits, 
so  that  a  negative  result  at  thirty  minutes  is  regarded  as  strongly  sug- 
gestive of  functional  incapacity,  and  still  longer  delay  is  still  greater 
evidence. 

Casper's  Phloridzin  Test. — ^The  glycosid  in  exact  dose  is  injected,  the 
ureters  are  catheterized,  and  separate  specimens  are  taken  during 
definite  periods,  for  example,  every  quarter  hour  or  half-hour,  securing 
one  or  several  specimens  from  each  kidney.  These  are  analyzed 
quantitatively  for  sugar  and  the  total  output  is  the  index  of  the  renal 
function. 

As  previously  stated,  by  using  the  same  number  of  specimens  and 
intervals  of  time,  Casper's  method  maybe  combined  with  Kapsammer's, 
doubtless  with  advantage. 

•  Xierendiagnostik  unci  Xicrenchirurgie,  1907,  T.  p.  87. 

*  Functional  Diagnosis  of  Kidney  Disease,  Am.  Ed.,  1903,  p.  58. 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS  851 

Results  and  Deductions. — The  phloridzin  test  determines  that  slow  or 
deficient  excretion  indicates  incapable  kidneys  and  danger  in  the  oper- 
ation. There  are  several  anomalous  reactions  to  this  test  by  normal 
kidneys  so  that  it  is  best  to  corroborate  it  when  possible. 

Beer'^  has  shown  that  in  this  functional  test  the  diseased  kidney  has 
an  influence  on  the  normal  kidney,  causing  either  inhibition  or  stimu- 
lation. Thus  both  negative  and  positive  results  may  be  misleading 
inasmuch  as  this  influence  disappears  when  the  diseased  organ  is  re- 
moved, and,  for  example,  a  kidney  seemingly  insufficient  resumes  full 
function  including  excretion  of  sugar  in  the  phloridzin  test.  It  is  not 
possible  to  say  whether  toxic  or  reflex  factors  or  both  combined  are  at 
work. 

Chromocystoscopy  (Indigocarmine  Test). — Physical  Basis. — The 
indigocarmine  test  or  chromocystoscopy,  which  is  the  other  term 
applied  to  this  test,  rests  on  the  hypodermic  or  intramuscular  injection 
of  0.16  gramme  of  indigocarmine  (carminum  coeruleum).  Through 
the  cystoscope  the  time  of  excretion  of  this  dye  is  noted  and  so  far  as 
possible  its  intensity  between  the  two  kidneys  estimated.  At  times, 
therefore,  ureteral  catheterization  may  be  avoided,  but  for  accurate 
comparison  had  best  be  carried  out.  The  intensity  of  the  dye  is 
sometimes  altered  by  the  reaction  of  the  urine,  especially  if  acid.  It 
is  therefore  well  to  try  the  effect  of  alkalinizing  the  specimens. 

Technic. — ^The  indigocarmine  test  requires  a  powder  or  tablet  contain- 
ing 0.16  gramme  of  the  dye  which  is  dissolved  in  10  c.c.  of  freshly 
distilled  water  and  brought  to  a  boil  but  not  to  actual  boiling  for  sterili- 
zation. Subcutaneous  or  intramuscular  injection  is  made  of  a  definite 
portion  of  this  solution  in  accordance  with  the  intensity  of  the  test 
desired.  Excretion  begins  promptly  and  continues  for  twenty-four 
hours. 

In  healthy  kidneys  the  dye  usually  appears  in  from  ten  to  twelve 
minutes,  although  the  time  and  intensity  may  vary  a  little  between  the 
two  sides.  For  exact  determination,  therefore,  the  writer  prefers  to 
catheterize  the  ureters. 

In  diseased  kidneys  the  excretion  of  the  dye  is  usually  delayed  in 
more  or  less  proportion  with  the  degree  or  extent  of  the  lesion.  This 
fact  is  another  reason  for  catheterizing  the  ureters,  because  the  normal 
kidney  may  excrete  the  dye  so  rapidly  and  intensely  as  to  obscure  the 
cystoscopic  examination  of  the  time  and  degree  of  the  excretion  from 
the  diseased  side. 

Kapsammer^  regards  the  time  of  appearance  of  the  dye  as  important 
in  estimating  the  functional  capacity  of  the  kidneys  precisely  as  he 
does  in  the  phloridzin  test.  It  is  better,  however,  to  combine  both 
the  qualitative  and  the  quantitative  methods  in  all  these  tests  when 
possible,  hence  the  intensity  of  the  color  should  be  studied  and  regarded. 

Kapsammer  found  that  in  properly  functioning  kidneys  the  blue 
color  appears  in  ten  or  twelve  minutes.    If  instead  of  blue,  a  green  color 

1  Jour.  Am.  Med.  Assn.,  1908,  1,  1972. 

2  Nierendiagnostik  und  Nierenchirurgie,  1907,  i,  78. 


852  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

appears,  functional  disturbance  is  indicated.  The  later  the  appearance 
of  the  color  the  more  serious  the  state  of  the  kidneys.  With  normal 
function  the  elimination  lasts  on  an  average  twenty-four  hours.  He 
injects  O.IG  grannne  into  the  quadriceps  a  hand's  breath  above  the 
knee.  The  author  would  add  that  in  normal  kidneys  a  green  color  is 
often  seen  when  the  urine  has  a  deep  yellow  or  orange  color,  because 
blue  when  mixed  with  yellow  or  orange  produces  green. 

In  the  United  States  valuable  work  has  been  done  in  this  field  by 
Thomas,'  Beer-  and  Furniss.^ 

Advantages. — The  indigocarmine  test  concerns  chiefly  time-savhig, 
inasmuch  as  this  is  one  of  the  most  prompt  methods.  Its  simplicity 
in  requiring  only  a  cystoscopy  is  a  factor,  but,  as  pomted  out,  ureteral 
cathctcri'/atidii  adds  to  its  accuracy. 

Phenolsulphonephthalein  Test. — Physical  Basis. — The  phenolsul- 
phonephthalein  test  is  performed  by  subcutaneous,  intramuscular  or 
intravenous  injection  of  0.006  gramme  of  this  dye  which  is  followed 
by  its  excretion  almost  totally  in  the  kidney.  The  test  includes  obser- 
vation of  the  time  of  its  first  api)earance  and  com])utati()n  of  the  amount 
passed  in  two  or  more  definite  periods,  usually  one  hour  or  thirty 
minutes  each.  It  therefore  combines  the  time — element  of  chromo- 
cystoscopy  and  the  time  and  quantitati^•e  elements  of  the  phloridzin 
tests.  By  healthy  kidneys  from  40  per  cent,  to  (10  per  cent,  are  excreted 
during  the  first  hour  and  from  20  per  cent,  to  25  per  cent,  during  the 
second  hour  after  the  injection.  The  time  of  the  first  appearance  of  the 
dye  is  with  healthy  kidneys  from  five  to  ten  minutes  after  subcutaneous 
or  intramuscular  injection,  and  from  two  to  i\\e  minutes  after  intra- 
venous administration. 

The  test  was  developed  and  described  by  Rowntree  and  Geraghty 
in  1910  and  is,  therefore,  one  of  the  newest  functional  tests. 

Advantages  and  Disadvantages. — The  advantages  usually  acknowl- 
edged are:  no  pain,  no  danger,  sterilization  by  active  })()iling,  absolute 
identity  by  its  color  even  in  a  drop  of  urine,  fixation  of  its  time  of 
appearance  even  in  mmute  traces  m  the  urine,  and  exact  quantitative 
analysis  of  its  excretion,  which  commonly  steadily  increases  to  the 
maximum  during  the  first  half-hour. 

Its  advantages  as  laid  down  by  R()^^■ntree  and  Geraghty*  may  be 
summarized  as  follows: 

1.  As  to  the  kidneys — total  excretion  of  the  dye  without  chemical 
change,  rapid  elimination  making  the  brevity  of  the  test  an  advantage 
hi  severe  cases,  absolute  nontoxicit>'  to  the  patient  or  the  kidneys, 
absolute  nonirritation  to  the  skin,  muscle,  vein  or  kidney  and  small 
dose  with  necessarily  less  likelihood  of  renal  disturbance. 

2.  As  to  the  test  itself — early  appearance  of  the  dye  in  the  urine, 
unmistakable  color  in  alkalized  urine,  comparative  independence  of 

1  Jour.  Am.  Med.  .^ssn.,  19i:i,  Ix,  1S.3. 

*  Ann.   Surg.,    190(i,   xliv,   .5.5:3. 

3  Surg.,  Gynec.  and  Obst.,  19i:},  xvi,  .56S. 

*  Arch.  Int.  Med.,  1912,  ix,  284.  Geraghty:  Jour.  Am.  Med.  As.sn.,  191.3,  Ix,  191. 
Geraghtj',  Rowntree  and  Cory:  Ann.  Surg.,  191:3,  Iviii,  800. 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS  853 

this  color  of  eflPects  from  urinary  pigments,  ready  and  positive  colori- 
metry  for  quantitative  determination  through  this  positive  (;o]or  tone 
with  consequent  easy  laboratory  teehnie. 

The  chief  disadvantage  of  the  phenolsulphojici^htliaiein  test  is,  after 
all,  trivial.  Acid  urine  gives  a  deep  canary  yellow  ajid  must  be  alkalized 
in  order  to  bring  out  the  true  tone  of  the  phthalein.  Ammoiiiacal 
urine  must  first  be  acidified  with  hydrochloric  acid  and  then  alkalized; 
as  in  ammoniacal  specimens  a  peculiar  brick-red  color  results. 

Technic. — The  phenolsulphonei)hthalein  test.  Stimulation  of  the 
kidneys  is  secured  by  giving  the  patient  250  to  500  c.c.  of  water  to  drink 
from  fifteen  to  thirty  minutes  before  the  injection,  then  1  c.c.  of  the 
solution  of  the  dye,  containing  0.006  gramme,  is  injected  preferably 
intravenously,  otherwise  subcutaneously  or  intramuscularly.  Very 
convenient  ampoules  are  now  on  the  market  containing  a  little  over 
1  c.c.  of  the  correct  solution  of  the  dye  so  that  very  exact  and  sterile 
dose  is  secured.  Ureteral  catheterism  must  be  performed  in  every  case, 
but  if  the  intravenous  route  is  chosen  it  must  precede  the  injection 
because  the  dye  usually  appears  in  less  than  five  minutes,  which  might 
not  be  enough  for  the  catheterization,  which  the  writer,  however, 
prefers  to  do  first  in  all  cases. 

A  bottle  for  the  urine  from  each  kidney,  containing  2  c.c.  of  25  per 
cent,  sodium  hydrate  solution,  is  placed  with  the  catheter  in  it.  When 
the  dye  appears  it  diffuses  itself  rapidly  through  the  fluid  so  that  the 
observer  must  be  careful  to  note  the  pale  pink  color  of  the  first  drop. 
The  time  of  the  appearance  of  the  first  drop  is  important  and  the  differ- 
ence between  the  two  sides  should  be  recorded.  Good  kidneys  usually 
excrete  within  ten  minutes  after  subcutaneous  and  intramuscular  injec- 
tion and  within  five  minutes  after  intravenous  mjection.  The  longer 
the  delay  and  the  greater  the  difference  between  the  two  sides  in  time 
are  the  first  indexes  of  insufficiency. 

For  quantitative  determination,  two  specimens  are  taken,  originally 
at  one  hour  each,  more  recently  a  half-hour  each,  as  the  maximum 
output  is  reached  during  the  first  half-hour. 

The  colorimetry  is  proceeded  with  as  follows :  A  cubic  centimeter 
of  the  dye  is  raised  to  1000  c.c.  in  alkalized  distilled  water  and  a  definite 
volume  of  this  control  or  comparison  fluid  is  taken  as  a  standard  in  a 
special  container  of  the  various  instruments.  With  this  is  compared 
a  definite  volume  of  the  urine,  also  alkalized  and  raised  to  1000  c.c. 
distilled  water. 

If  the  volimie  of  the  urine  is  so  small  that  this  step  will  dilute  the 
color  beyond  the  limits  of  accurate  reading,  the  ^^'l•iter^  raises  the  urme 
to  the  nearest  volume  which  is  divisible  an  even  nmnber  of  times  into 
1000,  for  example,  100.  The  quantitative  determination  in  this  con- 
centrated solution  is,  in  this  example,  therefore,  ten  times  its  proper 
amoimt.  The  reading  should  therefore  be  divided  by  the  factor 
representing  the  number  of  times  which  the  subdilution  is  contained 
into  1000. 

1  V.  C.  Pedersen:  Tr.  Am.  Urol.  Assn.,  1915,  ix,  374. 


854  THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 

Another  correction  of  the  detennmation  nnist  be  made  lor  sub- 
division of  the  specimens  into  equal  parts  for  other  analyses  in  cor- 
roboration of  tliis  test.    If,  therefore,  such  halvino-  has  been  made,  the 


Fig.  288. — Dilating  catheter.s  to  prevent  leakage  into  the  bladder. 


Fig.  289. — Subdivision,  in  the  bottle,  and  .subdilution  in  the  .smaller  graduate. 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS  855 

resulting  reading  must  l)e  niultij)lie(l  by  two,  inasinucl)  as  i\ui  total  out- 
put in  the  given  period  of  time  is  contained  in  the  whole  and  not  half 
of  the  specimen. 

Another  caution  of  the  determination  is  the  o})servation  of  loss  during 
the  injection.  A  cubic  centimeter  of  the  solution  as  furnished  in  tlie 
market  is  10+  minims.  A  loss,  therefore,  of  one  drop  in  })lowing  out 
the  air-bubble  from  the  hypodermatic  syringe  would  indicate  a  loss  of 
fully  6  per  cent,  of  the  dye  injected.  This  may  be  compensated  for 
either  by  arithmetical  computation  or  by  making  up  the  test  solution 
one  drop  short  of  a  cubic  centimeter.  This  refinement  is  necessary  in 
exact  observations  only.  Ordinary  care  and  judgment  alone  are 
required  for  practical  results. 

The  Duboscq  Colorimeter  is  the  most  accurate,  expensive,  and  cumber- 
some instrument,  and  for  practical  purposes  gives  no  advantages  over 
the  simpler  varieties  of  instrument.  The  technic  with  the  Duboscq 
instrument  is  as  follows,  according  to  the  circular  of  instructions,  from 
which  liberal  quotations  have  been  made: 

Path  of  Light  Through  the  Duboscq  Instrument. — The  diffused  light, 
ordinary  daylight,  lamp  or  a  monochromatic  burner,  after  being 
reflected  on  to  a  mirror,  is  separated  into  two  beams,  which  penetrate 
respectively  into  the  two  tubes.  The  right  beam  is  reflected  twice  in 
the  right  half  of  a  prism;  penetrating  into  the  eye-piece,  it  only  affects 
the  right  half  of  the  field;  the  left  beam  exactly  similarly  affecting  only 
the  left  side  of  the  field.  No  bright  light  is  needed;  it  is  sometimes 
better  to  place  before  the  mirror  a  piece  of  ground  glass,  such  as  is 
supplied  with  the  instrument. 

Instructions  for  Using  the  Duboscq  Colorimeter. — This  instrument 
gives  relative  results.  Place  standard  colored  liquid  in  left  tube. 
Place  liquid  to  be  compared  in  right  tube.  Now  lower  the  right  tube 
until  it  reaches  what  appears  to  be  the  most  convenient  point  for 
estimation,  which  depends  on  the  color  of  the  liquids,  and  note  the 
divisions  on  scale  corresponding  to  the  standard  liquid.  Lower  the 
tubes  until  they  touch  the  bottom  and  the  verniers  mark  zero.  Look 
through  the  eye-piece  and  move  the  apparatus  until  both  half  fields 
are  equally  illuminated,  and  then  move  screws  until  equality  of  tone 
is  produced.  For  two  liquids  the  color  is  inversely  proportional  to 
the  density  of  the  column  of  liquid  traversed  by  the  light  and  propor- 
tional to  the  quantity  of  dissolved  matter.  For  example,  suppose  a 
liquid  gives  a  reading  of  12™5,  and  the  standard  is  10'",  we  shall  then 
have  the  following  proportion: 

Color  of  liquid  Height  of  standard         lO*" 

Color  of  standard  Height  of  liquid  12'"o 

SO  the  color  of  the  standard  bemg  represented  by  1,  that  of  the  liquid 
win  be  0.8. 

To  clear  the  tubes:  raise  the  piston,  take  out  the  tube,  miscrew  the 
ring,  and  take  off  the  glass  at  bottom.  The  rest  can  be  easily  cleansed 
by  means  of  a  fine  cloth. 


856  THE  URETERS  AXD  REXAL  FUXCTIONAL  TESTS 

The  duv(')\s-al  Colon iiicfcr  is  ;naihil)lo  for  a  lari:;('  variety  of  medical 
tests,  including  the  phenolsulphonephthalein  quantitative  analysis.  It 
is  sufficiently  accurate,  inexpensive  and  convenient,  and  portable  in 
an  ordinary  instrument  bag. 

It  consists  of  the  following  i)arts:  a  neat  wooden  box  with  black 
face  and  interior  to  i)revent  optical  error.  In  the  black  face  is  a  small 
horizontal  slit,  behind  which  is  a  45°  x  45°  prism,  which  bruigs  the  two 
columns  of  color  from  the  standard  and  the  test  solutions  side  by  side, 
with  a  fine  line  between.  On  the  left  of  the  box  is  a  little  slide  and  cup, 
which  is  a  segment  of  a  wedge  like  the  standard  solution  wedge  for 
containing  an  exact  cubic  centimeter  of  the  urine.  On  the  right  of  the 
box  is  a  little  pinion  for  raising  and  lowering  the  wedge  of  standard 
solution  mitil  it  matches  the  test  solution.  The  back  of  the  box  slides 
up  and  down  by  means  of  a  rack  which  meshes  with  the  phiion.  The 
back  is  whidowed  almost  from  to})  to  bottom  with  a  wide  piece  of  milk- 
colored  glass,  in  front  of  which  is  momited  with  suitable  retainers  above 
and  below  a  glass  wedge  for  the  standard  solution,  held  with  its  vertical 
face  forward  parallel  with  the  vertical  face  of  the  cup  for  the  test 
solution  previously  noted.  On  the  left  of  the  back  is  a  scale  reading 
from  zero  to  one  hundred  so  placed  as  to  overlap  an  indicating  finger 
at  the  top  of  the  box  itself.  When  the  finger  is  at  0,  the  edge  of  the 
wedge  is  just  witliui  or  without  view,  and  when  at  100  the  deepest 
colmnn  of  the  fluid  withui  it  is  exactly  opposite  the  prism.  A  neat 
cover  makes  the  box  contaui  all  the  parts. 

The  universal  colorimeter  for  the  phenolsulphonephthalein  test  is 
used  as  follows:  The  standard  solution  is  made  up  in  the  manner 
])re\-iously  described  and  poured  into  the  wedge  imtil  completely 
filled  with  the  smallest  possible  air-bubl^le.  The  urine  to  be  tested  is 
also  prepared  as  detailed  and  the  contamer  filled  exactly  up  to  the 
cubic  centimeter  mark  of  the  wedge-shaped  cup.  Both  wedge  and  cup 
are  then  mounted  m  their  respective  slides  and  the  box  is  placed  with 
its  milk-glass  against  a  strong  light.  With  the  i)inion  the  wedge  is 
then  raised  vmtil  the  colors  in  the  prism  are  alike. 

The  wTiter  finds  it  convenient  to  make  the  determination  at  the 
usual  readmg  distance  and  then  at  20  feet,  and  to  shut  the  eyes  and 
suddenly  open  them,  in  order  to  gain  the  first  color  impression  as  dis- 
tinguished from  one  with  the  eyes  more  or  less  tired.  The  readuig  on 
the  scale  is  then  taken  directly  and  denotes  the  quantitative  result 
unless  there  has  been  error  in  the  loss  of  fluid  injected  or  in  subdilution 
or  in  subdivision  of  the  specimens  for  other  analyses  than  the  phenol- 
sulphonephthalein test,  as  previously  explained. 

The  method  of  estimating  quantity  excreted  using  the  Hellige 
Modified  Colorimeter  is  as  follows: 

First,  fill  the  wedge-shaped  cell  with  a  standard  solution,  made  by 
diluting  exactly  1  cubic  centimeter  (1  c.c.)  of  phenolsulphoneph- 
thalein solution,  from  an  ampoule,  with  about  200  c.c.  of  water, 
adding  10  c.c.  of  a  5  per  cent,  solution  of  sodium  hydroxide,  or  its 
equivalent,  and  sufficient  water  to  measure  one  liter.    Place  the  filled 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS  ^^i1 

cell  in  the  colorimeter.  Dilute  the  s})eciineii  to  alxmt  200  c.c.  with 
water  and  render  alkaline  by  the  addition  of  10  c.c.  of  a  5  per  cent, 
solution  of  sodium  hydroxide,  then  further  dilute  the  alkaline  urine 
with  sufficient  water  to  make  it  measure  one  liter.  EnoiiKh  of  this 
dilution  should  be  i)erfectly  clarified  by  filtration,  to  fill  the  rectangular 
cup  to  the  mark  that  will  be  found  upon  it.  The  cup  and  contents 
are  then  placed  in  the  apparatus  and  the  latter  manipulated  until  the 
colors,  as  seen  through  the  prism,  are  identical,  when  the  percentage 
of  excretion  will  be  directly  indicated  on  the  scale. 


B  A 

Fig.  290. — Hellige  colorimeter  R.  and  G.  modification:  A  is  the  instrument  with  its 
front  removed.  The  wedge-shaped  cell  for  the  standard  solution  is  shown  at  the  right,  the 
cup  for  urine  is  at  the  left.  The  ratchet  and  screw  are  at  the  right  for  elevating  the 
wedge  and  reading  scale  is  at  the  left;  B  is  the  closed  instrument  and  shows  the  obser\'a- 
tion  window. 

If,  after  adding  the  alkali,  the  coloration  of  the  specimen  is  slight, 
showing  small  excretion  of  the  phthalein,  then  the  dilution  should  be 
carried  only  to  250  or  500  c.c.  and  the  readings  on  the  scale  divided  by 
.4  or  2,  as  the  case  may  be. 

Cabot's  Colorimetric  Tubes  in  the  PhenolsulplioneplithaJein  Test. — 
The  apparatus  suggested  for  use  by  Hugh  Cabot^  consists  of  a  series 
of  ten  tubes  filled  with  dilutions  of  the  standard  solution  of  phenol- 
sulphonephthalein.    This  standard  solution  is  diluted  with  an  equal 

I  Boston  Med.  and  Surg.  Jour.,  October  12,  1911,  clxv,  Xo.  15. 


858  THE  URETERS  AXD  REXAL  FUNCTIONAL  TESTS 

volimie  of  water  and  placed  in  test-tube  marked  "50,"  which,  of 
coiu-se,  is  50  per  cent,  strength  of  the  standard  sohition.  The  other 
test-tabes  contain,  respectively,  45,  40,  35,  30,  25,  20,  15,  10  and  5 
per  cent,  dilutions.  When  niakintr  the  test,  the  si)eciinen  to  be  exam- 
ined is  compared  in  a  test-tube  of  the  size  of  those  containing  standard 
solutions  initil  one  is  found  to  match,  or  nearly  so.  The  test-tube 
should  be  as  nearly  hermetically  sealed  as  possible  and  considerable 
free  alkali  contained  in  the  test  sohition.  An  a<ldition  of  the  free  alkali 
is  necessary  on  account  of  the  absor})tion  of  carbon  dioxide  from  the 
air,  thereby  neutralizing  the  alkali,  resulting  in  the  changing  of  the 
color  of  the  solution,  unless  excess  of  alkali  is  present. 

In  order  to  check  up  readings  with  the  uni\"ersal  colorimeter,  the 
writer  has  modified  the  Cabot  method  in  the  following  way:  Ordinary 
4-<lrachm  homc()j)athic  ])hials  are  taken  and  filled  with  test  solution 
in  percentages  of  strength  graduated  from  100  to  10  by  tens  and  then 
four  additional  bottles  are  prepared,  namely  7^,  5,  2|  and  1  per  cent. 
When  tightly  corked  this  sun])ly  prepared  series  keeps  indefinitely  and 
is  very  convenient  for  \erifying  the  readings  of  the  wedge  in  the 
universal  colorimeter,  which  are  not  very  accurate  from  20  per  cent, 
downward. 

It  is  acknowledged  that  any  reading  within  5  per  cent,  may  be 
sufficiently  accm'ate  for  all  clinical  purposes.  On  the  other  hand,  still 
greater  exactness  is  attained  with  the  foregoing  facility,  and  may  in 
the  long  rmi  be  a  decided  gain. 

The  Dunning  Colorimeter. — This  instrmnent  is  a  modification  of 
Cabot's  and  is  useful  for  estimating  the  quantity  of  phenolsulphoneph- 
thalein  excreted  when  applying  the  Rowntree  and  Geraghty  Renal 
Functional  Test. 

To  estimate  the  quantity  excreted,  using  the  Dunning  colorimeter, 
dilute  the  specimen  to  about  200  c.c.  with  water  and  render  alkaline 
by  the  addition  of  10  c.c.  of  a  5  per  cent,  solution  of  sodiimi  hydroxide, 
then  further  dilute  the  alkaline  urine  with  sufficient  water  to  make  it 
measiu'e  one  liter.  Enough  of  this  dilution  should  be  perfectly  clarified, 
by  filtration,  to  fill  the  open  ampoule.  This  ampoule,  containing  the 
specimen,  should  then  be  placed  in  the  center  hole  of  the  colorimeter 
box  and  compared  with  the  sealed  and  marked  test  ampoules  until  the 
one  that  most  nearly  matches  the  s])ccimen  in  color  is  found.  From 
this  comparison,  the  phenolsulphonephthalein  content  of  the  specimen 
may  be  approximately  estimated.  More  rapid  and  closer  comparisons 
may  be  made  by  using  two  test  ampoules  at  a  time,  one  on  either  side 
of  the  specimen.  The  percentage  of  out])ut  between  the  ampoule 
numbers  may  be  more  closely  approximated  by  this  method. 

If,  after  adding  the  alkali  to  the  specimen,  the  coloration  is  slight, 
showing  small  excretion  of  the  "phthalein,"  then  the  dilution  should 
be  carried  only  to  250  or  500  c.c.  and  the  reading,  divided  by  4  or  2, 
as  the  case  may  be. 

Author's  Chart  for  the  Phenolsulphonephthalein  Test. — In  order  to 
combine  the  phenolsulphonephthalein  test  with  the  polyuria  test  and 


FUNCTIONAL  CAPACITY  OF  1 IIE  KIDNEYS  859 

with  physical,  chemical  and  bacterio]ogi(;al  analysis  of  the  specimens, 
and  if  desirable,  with  cryoscopy,  the  author  has  prepared  the  follow- 
ing method  and  chart,  having  two  sides,  respectively  for  the  original 
record  and  the  resume. 

PHENOLSULPHONEPHTHALEIN  TEST.  Name 

Date  Dr.  Hospital 

Provisional  Diagnosis: 

Final  Diagnosis: 

Excretion  in  serviceable  kidneys — 40%  to  60%,  1st  hour;  20%  to  25%,  2d  hour. 

Medication  Urine. 

Time.  and  Food. 

instrumentation.      C.  C.      S.  G.-    DYE.     C.  C.      S.  G.     DYE. 

Enipty\g,^,  J. [Catheter 

Irrig.    /  \C.  sheath      Distention  to         c.c. 

B.  P. 

Water  c.c. 

Telescope  in 
R.  U.  cath.  in 
L.  U.  cath.  in 
Water  c.c. 

Water  c.c. 

I  Urine 


B.  P. 


c.c.  dye  intravenously  (       drops  lost). 


B.  P. 

Water  c.c. 

Water  c.c. 

II  Urine 

B.  P. 

Water  c.c. 

Urine  III 

B.  P. 

Urine  IV 

"     V 

"     VI 

"     VII 

"     VIII 
Average  Specific  Gravity 


S60 


THE  URETERS  AXD  REXAL  FUXCTIOXAL  TESTS 


HOUR. 

Urine  I 

Urine  II 

Total 

Urine  III 

Total  I-III 

Urine  IV 
"     III— IV 
"     I— IV 
"     V— VIII 

Grand  Total 


RESUME 

I'rino  by 

Time.  Water  Fooil  pcrimls 

elapsed  tiurinn  during  iluriii^ 

by  periods,   first  hour.     24  hours.     21  hours. 


DYE. 
Inject.         Excret. 


Blood 
pressure. 


REMARKS:       {Readings  corrected  for  errors  in  scale,  loss  in  injeclion,  subdivisions 
and  subdilulions.) 

Food: 


Decrease 


Water : 

Standard  quantity 

Urine 

polyuria  curve: 

Dye 

Max.                                Min. 

Blood  pressure 

CONCLUSIONS: 

It  will  be  noticed  that  the  time  column  permits  one  to  be  as  detailed 
as  he  desires,  even  including  record  for  the  preparation  of  the  bladder 
and  the  insertion  and  withdrawal  of  instruments.  The  distention  of 
the  bladder  should  be  known  in  order  to  determine  leakage  around  the 
catheters  diu-ing  the  observation. 

B.P.  is  the  abbreviation  for  blood  pressure,  and  should,  in  the 
opinion  of  the  WTiter,  be  taken  before  the  water  drinking  and  at  the 
time  of  each  specimen  of  urine.  If  the  water  drinking  is  in  divided 
doses,  observations  in  the  blood  pressure  may  be  made  oftener,  if 
desired.    A  reading  should  be  taken  after  the  injection  of  the  dye. 

The  writer  is  rather  convinv^ed  that  the  blood  ])ressure  curve  follows 
the  polyuria  curve  and  the  excretion  of  the  dye.  In  other  words,  when 
the  kidneys  are  reasonably  able  to  perform  their  functions  or  when  one 
kidney  is  so  doing,  the  blood  pressure  will  rise  with  the  drinking  of  the 
water  and  reaching  its  maximum  during  the  greatest  excretion  of  thC' 


FUNCTIONAL  CAPACITY  OF  THE  KIDNEYS  801 

water,  decline  again  when  the  urinary  excretion  has  ceascfl  to  show 
polyuria.  The  blood  pressure  also  rises  with  the  injection  of  the  dye 
and  in  serviceable  kidneys  falls  as  the  excretion  of  the  dye  does  during 
the  second  hour.  The  writer  therefore  expects  to  see  at  the  end  of  the 
second  hour,  three  things,  in  serviceable  kidneys  or  kidney,  viz.,  decline 
of  the  curve  to  almost  normal  or  actual  normal  of  polyuria,  blood  pres- 
sure and  dye  elimination. 

It  is  almost  needless  to  add  that  these  findings  are  corroborated  by 
the  older  forms  of  investigation. 

Urine  I  is  taken  at  the  end  of  fifteen  minutes  before  the  polyuria 
curve  ordinarily  begins  and  furnishes  a  control  specimen  for  the  various 
analyses,  and  thus  will  show  whether  the  injection  of  the  dye  has  dis- 
turbed the  kidneys. 

Urine  II  is  taken  at  the  end  of  the  first  half-hour  or  hour  after  the 
injection  of  the  dye  in  the  choice  of  the  operator,  and  Urine  III  at  the 
end  of  the  second  half-hour  or  hour,  as  the  case  may  be. 

Inasmuch  as  85  per  cent,  is  considered  the  maximum  excretion  of 
the  dye,  and  as  frequently  even  normal  kidneys  give  as  little  as  60 
per  cent,  in  the  same  period,  viz.,  the  first  two  hours,  the  writer  is 
rather  fond  of  proceeding  as  follows,  if  the  condition  of  the  patient 
and  the  circumstances  of  the  test  permit.  The  catheters  are  withdrawn 
when  Urine  III  is  secured,  and  the  bladder  is  emptied  of  washings  and 
leakage,  whose  content  of  dye  is  determined  and  recorded.  Specimens 
of  urine  are  then  secured  for  the  balance  of  the  twenty-four  hours 
following  the  test,  as  follows: 

Urine  IV  at  the  end  of  the  eighth  hour  and  Urine  V,  VI,  VII  and 
VIII,  respectively,  at  the  end  of  the  twelfth,  sixteenth,  twentieth  and 
twenty-fourth  hour. 

The  observations  of  this  period  of  twenty-four  hours  are  when  the 
state  of  the  patient  and  the  limitations  of  the  test  permit  compared 
with  a  twenty-four  hour  specimen  of  urine  obtained  in  the  usual  way, 
and  analyzed,  and  with  another  twenty-four  hour  specimen  after  injec- 
tion of  the  dye  but  without  any  vesical  instriunentation  whatever, 
excepting  very  gentle  catheterization  of  the  urethra  to  secure  specimens 
at  the  foregoing  periods. 

Thus,  in  the  writer's  opinion  a  thorough  investigation  of  the  renal 
function  will  be  had  by  the  study  of  three  twenty-foiu*  hom-  specimens 
obtained  in  the  foregoing  manner  and  subjected  to  all  the  accepted 
usual  tests.  Of  course,  it  is  understood  that  there  are  many  kidney 
cases  of  acute  character  or  depreciated  condition  so  that  such  a  test 
might  not  be  altogether  advisable.  On  the  other  hand,  however,  there 
are  very  many  patients  who  will  be  benefited  by  the  rest  in  bed  for 
three  days  preparatory  to  any  operation,  of  which  two  days  are  indi- 
rectly preparatory  to  the  functional  test,  during  which  the  simple 
matter  of  taking  twenty-fom*  hoiu*  specimens  at  first  without  and  then 
with  injection  of  the  dye,  is  carried  out,  certainly  without  any  reason- 
able likelihood  of  harm. 

It  is  needless  to  say  that  such  a  study  of  the  case  is  laborious,  but  it 


S62  THE  URETERS  AXD  REXAL  FUXCTIONAL  TESTS 

will  yield  results  if  done,  as  far  as  possible,  in  the  same  condition  of  diet 
and  rest  in  bed  and  other  circiunstances  of  the  patient. 

On  the  back  of  the  chart  is  the  resume  in  the  upper  half  of  the  sheet, 
whose  columns  sufficiently  explain  themselves.  It  will  be  noted  that 
the  important  specimens,  Urines  I,  II  and  III  form  a  unit  in  the 
resume,  while  the  remaining  specimens,  IV  to  VIII,  inclusive,  are 
another  unit. 

The  lower  half  of  the  page  is  set  apart  for  remarks  on  the  observa- 
tions, corn'ctions  and  fonclusicMis,  and  needs  no  elucidation. 

Sequence,  Correlation  and  Comparison  of  the  Various  Functional 
Tests. — From  what  has  already  been  said,  the  advisability  will  be 
seen  of  analyzing  kidney  cases  in  an  orderly,  systematic,  thorough 
manner.  A  careful  subjective  and  objective  investigation  of  the  case 
with  special  stress  on  a  physical  examination  of  the  kidney  zone  must 
be  had  first.  Then  the  preliminary  of  the  functional  tests  is  withdrawal 
of  all  foods,  drinks  and  drugs  for  a  definite  period,  usually  accepted  as 
six  hours.  The  second  step  is  the  preparation  of  the  patient  and  the 
bladder  for  cystoscopy  and  ureteral  catheterism  as  detailed  in  previous 
pages.  If,  as  should  be  the  case,  sequence  and  corroboration  of  the 
various  functional  tests  are  desired,  the  best  selection  in  our  present 
knowledge  is  artificial  glycosuria,  artificial  polyuria,  and  one  of  the 
dye  tests,  by  preference  phenolsulphonephthalein. 

After  the  preparation,  therefore,  the  artificial  glycosuria  test  is 
begim  in  the  manner  laid  down  in  pre\'ious  paragraphs  of  this  chajjter. 
At  the  end  of  ten  minutes,  before  sugar  ordinarily  appears,  specimens 
from  each  kidney  are  taken  and  set  aside  for  the  established  method 
of  physical,  chemical,  microscopical  and  bacteriological  analysis.  At 
the  end  of  fifteen  minutes  and  every  five  minutes  thereafter  up  to  the 
first  thirty  minutes,  specimens  are  taken  to  determine  the  time  of  the 
appearance  of  the  sugar  after  the  method  of  Kapsammer  qualitatively, 
and  by  preference,  also  quantitatively,  after  the  method  of  Casper, 
If  desired,  these  four  fi^•e-minute  specimens  may  then  be  combined  and 
examined  exactly  like  the  first  for  any  change  in  excretion  under  the 
influence  of  instruments  and  drug.  Thus  may  be  diagnosticated 
chronic  parenchymatous  nephritis  by  low  specific  gravity,  albumin, 
casts  and  slow  and  low  output  of  the  drug.  As  a  rule,  further  functional 
test  in  such  kidneys  is  not  worth  while.  If  all  five  specimens  for  sugar 
at  the  end  of  the  first  half-hour  are  negative,  the  artificial  glycosuria 
test  may  be  regarded  as  useless. 

Artificial  polyuria  is  the  next  step.  If  500  c.c.  of  water  were  given 
before  the  glycosuria  test  was  begun,  no  further  drinking  will  be  neces- 
sary as  the  incidence  of  the  polyuria  begins  at  the  end  of  the  first  half 
hour  and  proceeds  as  already  described.  Otherwise  such  a  draught 
of  water  must  now  be  given  and  this  test  carried  forward  as  described. 

The  phenolsulphonephthalein  test  is  the  last  of  the  combination 
and  may  be  begun  at  the  end  of  the  second  half-hour.  While  the  poly- 
uria curve  is  reaching  its  maximum  during  the  third  half-hour,  this 
dye  is  also  attaining  its  highest  output.    If  two  periods  of  a  half-hour 


CHEMICAL  HEMATOLOaY  803 

each  are  adopted  in  the  phenf)Isijli)honephthalein  test,  its  last  period 
will  correspond  with  the  fourth  half-hour  of  the  polyuria  test  anf]  thus 
the  two  will  reach  their  decline  together  and  the  three  tests  cov(;r  only 
two  hours  and  a  half  of  time. 

Chromocystoscopy  or  the  indigo-carrnin  test,  is  only  qualitative 
and  therefore  not  reckoned  among  the  most  satisfactory  three  tests. 

This  plan  of  procedure  obviously  permits  in  addition  to  the  estab- 
lished analyses,  observation  of  the  glycosuric,  polyuric  and  chromic 
curves  in  mutual  comparison  and  corroboration. 

CHEMICAL  HEMATOLOGY. 

Significance. — Bilateral  or  combined  renal  efficiency  is  proved  by 
chemical  analysis  of  the  blood  for  retention  of  urea,  uric  acid,  crea- 
tinine, sugar,  salts  such  as  chlorids  and  phosphates  and  other  less 
important  and  usual  elements.  All  are  increased  or  varied  in  degrees 
proportional  with  the  kidney  disease.  Bilateral  efficiency  is  usually 
fully  designated  in  this  way,  but  when  cystoscopy  and  catheterization 
of  the  ureters  show  one  kidney  to  be  practically  without  function, 
then  chemical  hematology  may  be  regarded  as  applying  to  the  active 
organ. 

The  purely  mathematical  formulae  of  Ambard^  and  McLean^  for 
physiological  processes  are  confusing  and  unnecessary.  Clinical 
requirements,  as  demonstrated  by  Folin,^  mean  simple  quantitative 
analyses  for  whose  laboratory  details  the  reader  must  consult  works 
on  clinical  chemistry  or  clinical  diagnosis,  but  each  of  the  foregoing 
elements  requires  individual  note. 

Urea  in  the  Blood. — Urea  is  largely  of  exogenous  origin  and  there- 
fore variable  with  the  nitrogenous  quality  and  quantity  of  food.  Its 
prompt  response  to  changes  in  diet  makes  it  a  good  index  of  the 
progress  and  results  of  treatment. 

Its  range  in  health  is  narrow  and  between  12  and  15  milligrams  per 
100  c.c.  of  blood.  Larger  quantities  are  constant  and  proportional 
with  temporary  and  permanent  disease  of  the  kidneys  through  decrease 
of  elimination  and  subsequent  accumulation  in  the  blood.  Pathological 
renal  conditions  show  variations  between  15  and  50  milligrams  per 
100  c.c.  of  blood,  and  the  larger  the  quantity  the  more  serious  the  out- 
look. Widal's^  teaching  is  summed  up  in  the  thesis  of  his  student 
WeilP  in  these  statistics :  Twenty-eight  cases  with  over  300  milligrams 
of  blood  urea  per  100  c.c.  of  blood  all  died  in  from  one  week  to  five 
months  and  ten  days.  Forty-three  with  blood  urea  between  200  and 
300  milligrams  per  100  c.c.  of  blood  all  perished  between  one  week  and 
seven  months  and  sixteen  days.  Hence  there  is  practically  no  differ- 
ence between  these  ranges.    Weill  gives  no  corresponding  figures  for 

1  Compt.  rend.  Soc.  de  Biol.,  1910,  Ixix,  411,  506. 

2  Jour.  Exp.  Med.,  1915,  xxii,  212,  366;    also  Jour.  Am.  Med.  Assn.,  1916,  Ixxi,  415. 

3  Jour.  Am.  Med.  Assn.,  1917,  Ixix,  1212. 

^  Quoted  by  Simon,  loc.  cit.,  pp.  104  and  689. 
6  These  de  Paris,  1913. 


864:  THE  URETERS  AND  REXAL  FUNCTIONAL  TESTS 

100  to  200  iiiillisxraiiis  or  for  loss  tlian  100  inillliiranis.  Elsewhere  he 
states  that  while  exceptionally  a  large  quantity  like  7()  milligrams 
per  100  c.e.  of  blood  may  decrease,  as  a  rule,  the  content  steadily 
increases,  going  from  00  to  70  or  even  80  milligrams  and  thereafter  to 
100  milligrams  per  100  c.c.  of  blood.  From  100  to  200  milligrams  give 
a  sombre  ])rognosis.  With  such  patients  life  is  rarely  more  than  one 
year,  and  between  200  and  300  milligrams  it  is  only  months  or  weeks. 
Over  300  milligrams  are  only  seen  in  terminal  stages.  Still  more 
recently  AVidal,  Weill  and  Pasteur  Valery-Uadot,'  in  discussing  stop- 
ping places  in  azotemia  in  nephritis,  make  the  following  statements: 

1.  Xephritics  with  azotemia  of  100  milligrams  of  urea  to  100  c.c. 
of  blood  without  retrogression  almost  always  succmnb  within  two 
years. 

2.  If  the  urea  is  increased  but  does  not  reach  the  lunit  of  100  milli- 
grams to  100  c.c.  of  blood,  the  evolution  of  the  disease  cannot  be 
foretold  in  the  same  way.  A  single  determination  of  urea  of  100 
milligrams  in  100  c.c.  of  blood  need  not  mean  anything.  This  is  a 
corollary  of  the  first  observation. 

3.  Persistent  elevation  of  Ambard's  constant,  even  if  the  blood  urea 
is  normal,  may  be  regarded  as  a  preliminary  to  azotemia. 

4.  If  200  milligrams  and  upward  of  urea  per  100  c.c.  of  blood  are 
present,  death  may  be  expected  rather  early — the  sooner,  the  higher 
the  figure. 

Squier  and  ]^lyers'-  have  observed  that  among  hospital  patients  over 
15  milligrams  is  common  and  that  quantities  above  20  during  restricted 
protein  food  indicate  deficient  renal  function.  In  their  hands  urea  has 
been  a  more  valuable  anteoperative  prognostic  test  than  any  other. 

Decrease  of  renal  elimination  in  interstitial  nephritis  and  in  surgical 
conditions  of  the  kidney  is  the  common  cause  of  retained  urea  and  its 
increased  percentage  in  the  blood.  The  latter  fact  determines  its  value 
as  a  test  of  efiiciency.  In  eclampsia  according  to  Simon^  fatalities  show 
smaller  amounts  of  urea  than  recoveries,  which  indicates  both  decreased 
formation  and  elimination. 

Uric  Acid  in  the  Blood. — Uric  acid  is  allied  and  cognate  to  urea  in 
its  origin,  significance  and  variations.  Its  normal  range  is  2  to  3  milli- 
grams per  100  c.c.  of  blood,  which  marks  its  changes  within  very  narrow 
lunits  for  health. 

By  older  authorities  it  is  not  enumerated  as  a  constituent  of  normal 
blood.  From  this  viewpoint  blood  containing  m"ic  acid  is  not  normal 
and  likew^ise  kidneys  causing  its  appearance  in  the  blood  are  deficient. 
Hammerstein^  states  the  healthy  range  to  be  from  1  to  2.25  milligrams 
per  100  grams  of  blood.  Winterberg^  gives  the  average  as  0.9  milli- 
grams.    The  causes  of  increased  percentages  are  surgical  and  non- 

1  La  Prcsse  M6dicale,  1918,  xxxvi,  261. 

2  Jour.  Urol.,  vol.  ii,  No.  1. 

s  Clinical  Diagnosis,  1914,  p.  104. 
*  Physiological  Chemistry,  1914,  p.  334. 

s  Quoted  by  Hammerstein,  but  cannot  be  verified  in  Library  of  the  New  York  Academy 
of  Medicine. 


CHEMICAL  HEMATOLOGY  865 

surgical  types  of  renal  lesion.  Pneumonia,  leukemia,  cardiac  disease, 
pleurisy  with  effusion,  emphysema,  cyanotic  and  severe  anemic  con- 
ditions are  given  in  Simon's  work  as  other  causes. 

Noncoagulable  Nitrogenous  Compounds  in  the  Blood. — Ivar  Bangs^ 
states  that  the  physiological  content  of  incoagulable  proteins  is  from 
20  to  35  milligrams  for  each  100  grammes  of  blood. 

Farr  and  Austin^  found  15  to  43  milligrams  per  100  c.c.  in  various 
acute  and  chronic  diseases  without  kidney  lesions.  The  ammonia 
urea  element  was  50-60  per  cent,  of  the  stated  quantities.  Cardio- 
vascular disease  and  chronic  nephritis  do  not  alter  the  nonprotein 
nitrogen  or  ammonia  urea  in  amounts  and  relations,  although  albumin, 
casts,  edema  and  altered  phenolsulphonephthalein  permeability  may 
be  present.  In  chronic  nephritis  with  hypertension,  nonprotein 
nitrogen  increases  to  from  40  to  180  milligrams  per  100  c.c.  and  the 
percentage  of  ammonia^  urea  rises.  Fluctuations  are  rapid  and  wide. 
Improved  symptoms  are  accompanied  by  decreases  and  uremia  by 
increases  of  nonprotein  nitrogen.  No  constant  index  of  uremic  onset 
is  established. 

Analogous  to  urea,  uric  acid  and  creatinine,  these  proteins  accumu- 
late in  the  blood  during  the  types  of  renal  disease  stated.  Their 
observation  is  so  difficult  and  their  importance  so  questioned  that 
quantitative  study  is  infrequent. 

Creatinine  in  the  Blood. — Creatinine,  in  contrast  with  urea,  is 
chiefly  of  endogenous  origin  from  muscular  activity.  It  therefore  may 
indicate  deficiency  of  the  kidneys  better  than  urea  does.  Its.  dangerous 
accmnulations  appear  usually  after  urea  and  uric  acid  have  been 
doubled,  possibly  because  it  is  more  rapidly  eliminated.  Its  variations 
in  health  are  not  wide.  Gettler  and  Baker^  state  that  normal  blood 
contains  only  0.5  milligrams  per  100  c.c.  of  blood.  Other  authors  give 
the  range  as  1  to  2.5  milligrams.  Danger  is  indicated  by  3.5  milligrams 
according  to  Squier  and  Myers,  in  the  paper  already  cited,  and  fatali- 
ties by  5  milligrams.  Clu-onic  nephritis  acciunulates  2  to  3  milligrams 
and  uremic  nephritis  4  to  35  milligrams.  Poor  surgical  prognosis  is 
usually  indicated  by  elevations  of  creatinine;  but  contradictory 
findings  occur.  Squier  and  Myers  note  a  polycystic  kidney  case 
having  urea  nitrogen  75  milligrams  and  creatinine  8.3  milligrams, 
with  operation,  and  survival  for  a  year.  CampbelP  reports  a  bichlorid 
case  with  creatinine  12.5  milligrams  and  recovery.  ]\Iyers  and  Lough^ 
correlate  5  milligrams  with  fatalities  in  average  cases.  It  is  possible 
creatinine  must  be  interpreted  only  in  its  relation  to  lu-ic  acid  and  urea 
as  prognostic  signs. 

Cholesterin  in  the  Blood. — In  the  normal  blood  traces  occur. 
Matthews''  states  on  the  authority  of  several  chemists  that  the  total 

1  Methode  zur  Mikrobestimmung  einiger  Bluthestandtheile,  1916,  p.  28. 

2  Jour.  Exp.  Me'd.,  1913,  xviii,  241. 

3  Jour.  Biol.  Cheto.,  1916,  xxv,  221. 

4  Arch.  Int.  Med.,  1917,  xx,  919. 

6  Arch.  Int.   Med.,   1915,   xvi,  536. 

6  Physiological  Chemistry,  1916,  2d  ed.,  p.  85. 

55 


866 


THE  URETERS  AND  RENAL  FUNCTIONAL  TESTS 


cholesterine  content  of  the  human  blood  serum  is  from  1.17  to  2.95 
milliiirams  per  100  c.c.  of  blood.  In  a  blood  analysis  cholesterine  is 
avorajj;ed  at  1.23S  per  1000.  Sinion^  teaches  that  larger  quantities 
(.478  per  cent.)  associated  with  lipeniia  occur  in  diabetes  and  that 
special  biological  methods  show  smaller  amounts  in  tuberculosis  and 
syphilis.  In  chronic  interstitial  nephritis  it  varies  from  1.74  to  2.65 
milligrams  per  100  c.c.  of  blood  sera.  In  chronic  parenchymatous 
nephritis  5.59  to  10.00  millip'ams  i)cr  100  c.c.  of  blood  senim  occur 
and  it  is  markedly  increased  in  cases  of  fi;all-stones.  Cholesterin  is, 
therefore,  rather  a  better  index  of  jjall-bladder  disease  than  of  nephritis. 


BLOOD  ANALYSIS 

URINE  ANALYSIS^ 

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convalt  scent. 

it  Mo^r/te  amoinif 
f  Sma//  amount. 

Fig.  291.— (Gradwohl  and  Schislcr.) 


Sugar  in  the  Blood. — Accumulations  of  sugar  in  the  blood  may 
precede  the  excretion  of  sugar  in  the  urine.  The  normal  range  is  0.09 
to  0.12  per  cent.  Pathological  variations  are  0.16-0.17  in  early  diabetes 
and  0.2-0..3  in  advanced  cases.  According  to  INTyers  and  Bailey,^  even 
in  the  latter,  sugar  may  not  be  present  in  the  urine.  Simon''  says  a 
positive  blood  test  may  occur  while  sugar  is  absent  in  the  urine  tem- 
porarily. In  nephritis  there  is  less  diastatic  excretion  in  the  urine, 
hence  more  diastatic  activity  in  the  blood,  causing  the  production  of 
sugar.  This  is  a  partial  but  not  an  absolute  explanation.  In  diabetes, 
sugar  may  reach  0.4  per  cent,  and  in  diabetic  coma  it  not  uncom- 
monly exceeds  1  per  cent.,  associated  with  pronounced  acidosis, 
which  is  determined  by  excess  of  salts,  as  explained  in  the  following 
paragraphs. 


»  Op.  cit.,  p.  no. 

»  Op.  cit.,  p.  103. 


-  Jour.  Biol.  Clieiii.,  1910,  .\xiv,  147 


CHEMICAL  JIEMATOLOGY 


807 


Salts  in  the  Blood. — Edema  in  nephritis  is  caused  at  least  partially 
by  decreased  renal  excretion  of  sodium  chlorid  and  then  by  its  accumu- 
lation in  the  blood  and  tissues.  Acid  phosphate  of  soda  is  the  source 
of  acidity  of  the  urine  and  when  in  nephritis  it  is  retained  instead  of 
excreted,  acidosis  of  the  blood  results.  Affinity  of  the  blood  for  carbon 
dioxide  gas  among  waste  products  is  lowered  by  this  phosphatic  acidity, 
and  becomes  an  indicator  of  acidosis. 

In  diabetes  it  is  the  relation  among  the  three  elements  of  acidosis, 
carbon  dioxide  affinity  and  anesthetics  (especially  chloroform  and  less 
so,  ether)  which  marks  the  importance  of  chemiral  hematology  for 


THE  CHARAC 

GOUT.DIAI 

rERISTIC  BLOOD  PICTURES  IN     \  UREA  N,    URIC  ACID.  I 

BETES  &  NEPHRITIS  n   [CREATININE  &  SUGAR.) 

DISEASE 

UREA  N      URIC  ACID  |  CREATININE 

SUGAR 

MGMS.  PER    IOO?5   of    BLOOD 

PER  CENT 

NORMAL 

12-15 

1-3 

1-2.5 

0.08-0.12 

GOUT 

35-6 

MILD 
DIABETES 

015030 

SEVERE 
DIABETES 

- 

030UO 

CHRONIC 
NEPHRITIS 

1550 

14 

13 

UREMIC 
NEPHRITIS 

80300 

415 

434 

ai0020 

THERMIC 
FEVER 

UREA  N 

26- 
S9 

URIC  ACID 

6-14- 

CREATINIME 

3-S.I 

SUGA.R 
O.  IB- 
0.20 

Fig.  292.— (Gradwohl  and  Sehisler) 

renal  insufficiency  and  operative  prognosis.  A  corollary  is  the  claim 
of  Whitney^  that  acidosis  not  uncommonly  causes  death  in  nephritis 
rather  than  uremia. 

Recapitulation.— Gradwohl  and  Schisler^  in  a  study  of  thermic 
fever,  which  they  designate  as  "certain  symptom-complexes  that  are 
the  result  of  disturbances  of  heat  regulation,  primarily  from  physical 
causes,"  tabulate  their  results  with  regard  to  several  conditions 
associated  wdth  urinary  and  hemic  changes.  The  table  (Fig.  291),  on 
page  866,  epitomizes  their  results  clearly  as  to  special  cases  and  the 
above  table  (Fig.  292)  correlates  their  findings  in  six  important 
diseases  associated  with  alterations  of  blood  and  urine. 


1  Arch.  Int.  Med.,  1917,  xx,  931. 

-  Am.  Jour.  Med.  Sc,  September,  1917,  p.  407. 


CIIArTER    XVI. 

ACUTE  AND   CHRONIC  SUPPURATIVE  INFLAMMATIONS 
OF  THE  RENAL  PELVIS  AND  PAUENCHY^IA. 

Varieties. — Cystoscopists  are  directly'  interested  in  three  forms  of 
acute  sii])i)iiratiou  of  tlie  kidney,  iianiel>',  ])yelitic,  infarct  and  pyelo- 
nephritis, the  former  beinj;  usually  nono])crative  and  the  latter  two 
ahnost  invariably  operative  conditions,  and  they  are  concerned  in  one 
form  of  chronic  renal  suppuration,  namely,  pyonephrosis,  which  is 
scarcely  distinguishable  clinically  from  its  correlatives,  renal  abscess 
and  suppurative  nei)hritis. 

CATARRHAL  ACUTE  PYELONEPHRITIS. 

Catarrhal  Acute  Pyelitis. — Definition. — Catarrhal  acute  pyelitis  is 
usually  a  unilateral,  rarely  a  bilateral,  catarrhal  inflammation  of  the 
mucous  membrane  of  the  pelvis  of  the  kidney  and  lias  the  same  charac- 
teristics as  catarrhal  inflammation  of  any  other  mucosa  in  the  produc- 
tion of  swelling,  mucus  and  pus.  It  is  usually  accompanied  or  preceded 
by  obstruction  of  the  m-eter  and  dilatation  of  the  pelvis,  and  followed 
by  hyperemia,  congestion  and  enlargement  of  the  kidney.  The  disease 
is  usually  of  self-limited  type,  especially  if  the  obstruction  of  the  ureter 
is  readily  corrected  by  nature  or  treatment.  The  parenchyma  of  the 
kidney  is  therefore  not  infected  and  rarely  affected  clinically  beyond 
congestion  and  possibly  histologically,  possibly  not  at  all.  These 
facts  distinguish  it  from  other  sui)])urati\-e  kidney  conditions  of  chronic 
character,  namely — pyonephrosis,  which  is  really  a  later  de^'elopment 
of  pyelitis,  suppurative  nephritis,  in  which  the  parenchjina  is  pre- 
dominantly' infected,  and  suppurati^■e  ])yelonephritis,  in  which  both 
l)elvis  and  parenchyma  are  profoundly  involved. 

Etiology  and  Pathogenesis. — Pyelitis  is  either  ])rimary  or  secondary. 
The  primary  pyelites  arise  without  deflnite  assignable  cause  exactly 
as  do  catarrhs  of  the  nasal,  intestinal  and  vesical  mucosae,  as  examples. 
There  are  a  catarrhal  reaction,  infection,  edema,  m-eteral  obstruction 
and  moderate  pelvic  dilatation  as  features,  of  which  the  last  two  are 
produced  by  the  preceding  three  factors. 

The  set  ondary  pyelitis  follows  a  preliminary  obstruction  to  the  ureter 
as  in  the  pressure  of  pregnancy,  distortion  of  movable  kidney,  resist- 
ance of  extraureteral  and  intraureteral  stricture,  prostatic  enlargement, 
urethral  stricture,  and  the  like.  Cystitis  may  extend  its  infection  along 
the  ureter  to  the  pelvis,  and  pus  foci  elsewhere  in  the  body  may  be  the 
starting-point. 


CATARRHAL  ACUTE  PYELONEPIfRJTfS  869 

The  exciting  orjijanism  is  comiiioiily  the  J>ac-illns  ooli  f:omrnijnis, 
usually  proceeding  from  chronic  intestinal  disorders  which  in  this 
connection  become  extremely  important. 

Predisposing  causes  as  in  all  catarrhs  arc:  exposures  to  cold,  physical 
and  nervous  exhaustion  and  any  factor  inducing  sudden  internal 
congestion. 

Syndrome  and  Diagnosis. — In  outline  the  chief  complaints  of  the 
patient  are  as  follow:  The  ureteral  obstruction  and  renal  congestion 
cause  pain,  sudden  and  positive  in  the  affected  side.  The  infection  and 
urinary  absorption  produce  chilliness  or  chill  and  fever,  with  a  blood 
analysis  far  out  of  proportion  with  the  importance  of  the  disease, 
the  leukocytosis  being  12,000  to  15,000  and  the  polymorphonuclear 
leukocytes  as  high  as  85  to  90  per  cent,  or  above.  Reflex  action 
■produces  nausea,  vomiting,  depression,  shock  and  prostration  in  the 
system  at  large,  and  in  the  urinary  system  frequency,  urgency,  pain 
and  sometimes  tenesmus.  The  catarrhal  exudate  shows  as  mucus,  pus 
and  renal  and  pelvic  epithelia  in  the  urine. 

Physical  examination  reveals  affected  kidney,  as  a  rule  movable  and 
almost  invariably  enlarged  and  tender.  The  opposite  or  normal  kidney 
is  without  physical  signs  or  slightly  tender  from  congestion  in  the  more 
marked  cases.  Bilateral  cases  show  duplicate  or  correlative  conditions 
on  the  two  sides. 

Cystoscopy  and  ureteral  catheterization  alone  establish  the  diagnosis. 
The  cystoscopic  findings  resemble  those  in  hydronephrosis.  The 
mouth  of  the  ureter  on  the  affected  side  is  prominent  and  congested, 
sometimes  patulous  and  delivers  pus-laden  urine  in  driblets  and  not 
in  orderly  spurts. 

Ureteral  catheterization  delivers  from  the  affected  kidney  a  quantity 
of  urine  larger  than  the  pelvis  normally  holds,  thus  indicating  dilata- 
tion and  residual  urine,  especially  with  movable  and  displaced  kidney, 
and  pus  in  the  urine  from  the  catarrhal  process.  The  unaffected  kidney 
shows  a  urine  normal  in  quantity  and  in  character  except  for  the  occa- 
sional signs  of  renal  congestion.  The  sense  of  having  passed  an  obstruc- 
tion is  sometimes  present  on  the  affected  side. 

Differential  Diagnosis  is  based  on  the  following  considerations : 

Acute  invasion,  either  without  preliminary  history  or  wdth  the  his- 
tory of  movable  kidney,  to  attract  attention  to  the  renal  zone. 

Marked  persistent  pain  unrelieved  by  rest  and  unexcited  by  motion, 
focalized  in  the  affected  kidney  region,  particularly  in  the  costoverte- 
bral angle  of  the  loins. 

Chilliness  or  chill,  fever,  and  other  signs  of  mild  infection. 

Blood  count  of  acute  suppm-ative  process,  not  imcommonly  dispro- 
portional  with  the  severity  of  the  lesion. 

Pus  without  blood  in  the  urine. 

Tender  enlargement  of  the  affected  kidney,  grafted  on  a  movable 
kidney  or  one  in  its  normal  position. 

Reflex  muscular  protection  of  the  inflamed  organ. 

Ureteral  catheterization  on  the  diseased  side  reveals  slight  obstruc- 


870     IXFLAM.MATWXS  OF  REXAL  PELVIS  AXD  PAREXCIIYMA 

tioii  ill  tlu'  urottT,  sensitive  ]H'lvis,  ;ici(l  urine  hulen  witli  i)us,  pelvic 
epitlielia  and  pure  eulture  of  JJaeilli  eoli  coinunuiis  but  free  from 
parenchimatous  renal  involvement;  but  from  the  normal  kidney 
unchanged  urine  or  that  of  slight  congestion. 

The  course  is  brief,  the  disease  limits  itself  and  has  no  sequels  in 
the  ])aroncliynia   if  tlu'  cause  is  renioxed. 

Catarrhal  Acute  Pyelitis  of  Pregnancy. — Definition.— C'atarrhal  acute 
pyelitis  of  pregnancy  hardly  deserves  indi\idual  space  as  the  cases  of 
it  are  so  patently  dujilicates  of  all  other  cases  of  the  disease  with  the 
sole  fact  of  ])regnancy  added.  Accuracy  recpiires  limitation  of  the  term 
to  ])aticnts  \vith(Mit  history  of  pyelitis  previous  to  the  pregnancy. 

Etiology. — The  etiology  of  catarrhal  acute  pyelitis  of  pregnancy  is 
mechanical  pressiu-e  on  the  lu-eter  by  the  gravid  womb  usually  between 
the  third  and  last  month  of  normal  pregnancy.  The  infecting  organism 
is  the  Hacillus  coli  comnumis  in  pure  culture. 

Syndrome,  Diagnosis  and  Differential  Diagnosis. — In  catarrhal  acute 
pyelitis  these  are  the  same  as  hi  other  forms  of  the  disease. 

Cystoscopy  and  lu-eteral  catheterization  in  catarrhal  acute  pyelitis 
of  pregnancy  add  only  the  changed  form  of  the  bladder  due  to  the 
weight  of  the  pregnant  womb  and  sometimes  increased  difficulty  of 
entering  the  m-eter. 

Treatment. — The  treatment  is  nonoperative  and  operative. 

The  nonoj)erative  measures  almost  invariably  recjuire  waiting  for 
the  subsidence  of  the  acute  stage  and  the  establishment  of  the  quiescent 
period.  Exception  to  this  rule  is  the  case  where  severe  symptoms 
require  relief  by  entering  the  pelvis  wath  great  gentleness  and  caution. 
Evacuation  of  the  pelvis  is  the  first  step  in  all  cases  and  possibly  the 
only  detail  in  the  mild  cases.  Retention  of  the  catheter  for  drainage 
of  the  pelvis  for  several  hoiu-s  is  required  by  the  more  severe  cases. 
Lavage  of  the  pelvis  after  both  evacuation  and  drainage  for  cleansing 
with  solvents  of  mucus  and  pus  and  for  mild  sterilization  and  stimula- 
tion with  the  nonirritating  silver  salts  is  the  second  step  in  all  cases. 

Exactly  this  same  plan  of  treatment  is  required  in  the  pyelitis  of 
pregnancy. 

Operative  measm^es  require  replacement  of  prolapsed  and  movable 
kidneys  and  correction  of  any  obvious  obstruction  only  in  the  very 
severe  cases. 

Induction  of  labor  is  unnecessary  in  the  catarrhal  acute  pyelitis  of 
pregnancy  unless  the  fetus  is  dead  and  unless  the  persistence  and 
resistance  of  the  disease  to  treatment  threatens  parenchymatous 
damage  of  the  kidney. 

SUPPURATIVE  ACUTE  PYELONEPHRITIS. 

Acute  Unilateral  Septic  Infarct  of  the  Kidney. — Definition. — This 
disease  may  be  defined  as  the  lodgment  of  a  mass  of  hifective  material 
of  hematogenous  origin  in  the  parenchyma  of  one  kidney,  forming 
usually  multiple  infarcts  or  foci  of  infection.    Subsequent  suppuration 


SUPPURATIVK  ACUTE  PYELONEPHRITIS 


871 


Fig.  29.3. — Author's  case  of  septic  infarct  of  the  kidney  during  pregnancy.  Shows 
the  inner  surface  of  the  kidney  with  a  rather  large  pyramidal  infarct  at  the  border 
where  the  surface  of  the  kidney  is  broken.  In  the  fresh  specimen  this  was  almost 
diagrammatic. 


Fig.  294. — Septic  infarct  of  the  kidney.  Outer  surface  of  the  specimen,  showing  foci 
of  infection  near  the  upper  pole,  not  unlike  acne  pimples  on  the  face,  and  indicating 
extension  of  the  process  through  the  formation  of  adhesions  around  the  lower  pole. 
(Author's  case.) 


S72     IXFLAMMATIONS  OF  REXAL  PELVIS  AXD  I'A  fUCXCIIYMA 

and  .abscess-formation  are  frequent  and  usual  hut  are  not  absolutely 
essential  to  complete  the  j)atlu)louy. 

Extensi\e  researches  into  the  subject  of  infarcts  of  the  kidney  ha^e 
been  done  in  this  country  by  Brewer,^  Gibson,'-  Cobb/'  Johnson/  ]\iayo^ 
and  others,  while  in  Europe  Israel^  is  the  leading  authority  among 
many  others.  It  is  to  be  noted  that  of  these  six  authors  only  Brewer 
and  Cobb  use  the  term  "acute  unilateral  sei)tic  infarct."  The  other 
foiu'  s})cak  of  hematogenous  infection  or  metastatic  abscess. 

Etiology  and  Syndrome, — Acute  unilateral  septic  infarct  of  the  kidney 
is  a  lesion  which  is  more  common  in  women  during  the  child-bearing 
])eri()d  from  the  twentieth  to  the  fortieth  year,  than  in  men,  and  more 
fre(inent  on  the  right  than  on  the  left  side,  for  unknown  reasons.  The 
essential  basis  as  proved  by  Brewer^  is  tramnatism  of  the  kidney  and 
a  som'ce  of  the  infecting  embolus.  Thus  lowered  general  and  local 
resistance  are  important  elements. 

Symptoms. — The  acute  septic  process  with  very  rapid  invasion,  chill, 
high  fc\  er  with  wide  excursions,  hard,  rapid  pulse,  depression  and  pros- 
tration is  obvious.  The  focal  or  renal  symptoms  and  signs  are  com- 
paratively little  inasmuch  as  many  cases  show  scarcely  any  material 
change  in  the  urine,  facts  which  are  quite  disproportional  with  the 
toxemia  and  systemic  disturbance.  Acute  sensitiveness  in  the  kidney, 
especially  in  the  costovertebral  angle,  is  present. 

The  leading  subjective  complaints  are  pain  referred  to  any  point 
of  the  abdominal  cavity,  fever,  s^Tuptoms  due  to  septic  absorption  and 
prostration.  The  pain  itself  is  rarely  referred  to  the  exact  kidney  zone 
and  therefore  is  easily  confused  with  the  pain  of  extrarenal  organs 
such  as  the  gall-bladder,  stomach  and  duodenum  in  ulcer,  appendix 
and  pedunculated  cysts,  especially  ovarian. 

Objective  examination  alone  decides  on  the  elements  of  tenderness 
of  the  costovertebral  angle,  fixation  of  the  abdominal  wall  over  the 
kidney,  pus,  epithelia  and  blood  on  the  affected  side  if  present  in  cystos- 
cojjy,  the  sudden  onset  and  establishment  of  the  septic  state  with  or 
without  preceding  lesions  and  the  practical  absence  of  disturbance  of 
the  action  of  the  bladder. 

Cystoscopy  and  ureteral  catheterization  demonstrate  the  presence 
and  function  of  both  kidneys;  the  elements  of  the  disease  in  urine  on 
the  affected  side  if  the  foci  are  discharging  pus  and  blood  into  the  pelvis. 
Otherwise  the  urine  is  negative  except  for  the  early  signs  of  congestion 
and  the  later  signs  of  nephritis,  namely,  albumin,  casts,  epithelia, 
decrease  in  quantity  of  fluid,  urea  and  blood,  which,  if  alone,  might 
be  due  to  traumatism  of  the  ureteral  catheter.  Negative  urinary 
findings  may  accompany  profound  systemic  sjTnptoms  when  the  sup- 

1  Surg.,  Gynec,  aud  Obst.,  1906,  ii,  485;  New  York  Med.  Jour.,  l'J07,  Ixxxv,  1012; 
Ibid.,  1915,  ci,  550. 

2  Med.  News,  1905,  Ixxxvi,  435.  ^  Ann.  Surg.,  1908,  xlviii,  680. 
*  Am.  Surg.,  1899,  xxix,  10. 

'  Collected  Papor.s  of  the  Mayo  Clinic,  1915,  vii,  336  (published  in  1916). 
»  Chirurgische  Klinik  d.  Nieren  Kraukheiten,  1901,  p.  34. 
^  Surg,,  Gynec.  and  Obst.,  May,  1906. 


SUPPURATIVE  ACUTE  PYELONEPJIRJTJS  873 

purative  focus  is  subcapsular  and  does  not  evacuat(;  itself  into  the 
urinary  stream.    Such  negative  findings  may  also  persist  in  the  mild  cases. 

Treatment. — ^The  indications  laid  down  hy  lirewer  are  as  follows:' 
"In  regard  to  treatment,  the  cases  should  be  dividcid  into  three  classes: 

The  severe  type,  in  which  the  temperature  remains  high,  and  the 
toxemia  is  rapidly  progressive.  These  cases  require  nephrectomy  at 
the  earhest  possible  moment. 

The  milder  cases  are  those  in  which  the  initial  temperature  may  be 
high,  but  begins  to  fall  within  forty-eight  hours,  and  where  the  toxemia 
is  less  marked.  These  cases  may  often  be  successfully  treated  by 
decapsulation,  which  relieves  the  intense  congestion  and  allows  Nature 
to  complete  the  reparative  process.  Where  one  or  more  cortical 
abscesses  are  present  they  should  be  opened  and  drained. 

In  the  mildest  type,  the  case  may  be  treated  expectantly  with  a 
reasonable  prospect  of  complete  recovery,  although  the  writer  has 
observed  two  or  three  patients  in  which  a  chronic  pyelonephritis  has 
remained." 

Results. — The  outcome  is  given  by  Brewer  in  the  same  article  as 
follows  and  very  well  exemplifies  the  value  of  the  various  forms  of 
treatment : 

"Nephrotomy  and  drainage  in  five  patients  of  the  severe  tjq^e,  all 
died.  Nephrectomy  in  eight  patients  of  the  severe  type,  all  recovered. 
Nephrotomy,  decapsulation  and  drainage  in  five  patients  of  the  milder 
type,  all  recovered.  Expectant  treatment  in  four  or  more  patients  of 
the  mildest  type,  all  recovered." 

Suppurative  Acute  Pyelonephritis. — Definition  and  Pathogenesis. — 
This  renal  condition  is  an  entity  clinically  and  pathologically  and  not  a 
duplicate  of  pyelitis  but  rather  a  lesion  combining  both  pyelitis  and 
nephritis  of  suppurative  type. 

Pathologically  it  is  an  extension  into  the  parenchyma  from  the 
pelvis  and  the  ureter  of  suppuration,  commonly  grafted  on  trauma 
and  infection  of  the  kidney.  Foci  of  pus  and  their  extension  may  be 
secondary  to  pus  elsewhere  in  the  body.  The  infection  may  start  from 
the  bladder  and  follow  the  ureter  into  the  pelvis  and  the  kidney  in 
direct  continuity.  Urethral,  prostatic  and  other  urinary  obstructions 
may  be  primary  and  the  infection  secondary  and  thus  reach  the  kidney. 
Ureteral  fistulse  are  important. 

Etiology. — Suppurative  acute  pyelonephritis  has  a  causal  sequence, 
which  is  one  of  acute  suppurative  disease  due  to  preceding  factors  such 
as  trauma  and  depreciation  of  the  urogenital  organs.  In  yoimg  men 
urethritis  and  stricture,  in  old  men  prostatic  hypertrophy  and  neoplasm, 
in  females  repeated  pyelitis  of  pregnancy,  pus  tubes  and  pejiuterine 
peritonitis.  Injury  and  especially  transplantation  of  the  ureter  in 
operation  are  most  common  forerunners. 

Syndrome. — ^This  requires  a  careful  subjective  history  of  facts  leading 
up  to  antecedent  trauma  or  disease  of  the  kidney,  ureter  or  bladder. 

1  New  York  Med.  Jour.,  June,  1907. 


S74     IXFLAMMATIOXS  OF  REXAL  PELVIS  AND  PAREXCIIYMA 

Two  goiu'ral  groups  may  bo  generally  distinguished,  namely,  the  earlier 
and  milder,  and  the  later  and  se\'erer  cases. 

Systemic  s^inptoms  of  early  and  mild  pyelonephritis  are  those  of 
absorj)tion  due  to  inactive  form  of  sepsis,  irregular  fever  and  rigors, 
accelerated  tense  pulse,  prostration  and  tendency  to  anemia.  The 
symptoms  are  also  of  reflex  origin,  namely,  anorexia  and  gastrointestinal 
disorder. 

Focal  sjiiiptoms  of  mild  i)yelonephritis  include  ])ain  in  the  kidney 
on  the  diseased  side.  The  compensating  hy])ertro])hy  of  the  o])])osite 
kidney  with  its  congestion  during  exacerbations  of  the  disease  may  give 
more  sensitiveness  than  the  diseased  side. 


Fig.  295. — Acute  pyelonephritis,  inner  \ie\v.  Exten.sive  destruction  of  the  kidney 
in  the  calyces  and  the  pelvis,  likewise  thickening  and  infiltration  of  the  ureter.  In  the 
center  of  the  picture  are  the  calyces  opened  into  a  distinct  cavity  of  the  pelvis,  all  filled 
with  thick  detritus,  more  than  2  ounces  of  foul  fecaloid  pus,  but  no  stones  were  found  in 
this  cavity  which  opens  into  the  ureter  below,  which  is  shown  to  be  extensively  thickened. 
The  upper  pole  of  the  kidney  is  seen  to  be  destroyed  by  the  superficial  abscess.  (Author's 
case.) 


Dysuria  may  be  present  and  all  the  symptoms  of  cystitis  may  ante- 
date or  follow  the  s^inptoms  of  the  disease. 

If  a  divided  m-eter  with  secondary  fistula  has  been  the  source  of  the 
infection  the  bladder  will  be  without  focal  symptoms  but  m-ine  will  be 
discharged  at  the  distal  opening  of  the  fistula  in  the  skin,  bowel  or 
vagina,  as  examples. 

Late  se\'ere  pyelonephritis  renders  more  accentuated  all  the  fore- 
going symptoms  and  signs,  septic  absorption  increases  and  may  reach 
terminal  toxemia  and  true  septicemia. 

Perinephritic  abscess,  suppurative  acute  nephritis  and  renal  abscess. 


SUPPURATIVE  ACUTE  PY ELONKPII RITIH 


875 


all  show  the  same  elini(;al  and  (;ystos( o[n(:al  ]M(;tur(;  as  intense  pyelo- 
nephritis; in  fact,  suppurative  acute  nephritis  may  be  only  the  expres- 
sion of  an  active  exacerbation  of  the  chronic  form,  and  renal  abscess  is 
only  a  focal  suppuration,  which  may  give  all  the  signs  of  a  generalized 
infection. 


Fig.  296.- 


-Old  suppurative  pyeloureteritis.      (Author's  case,  from  surgical  and 
urological  services  of  St.  Mark's  Hospital.) 


Objective  s^nnptoms  of  acute  pyelonephritis  also  vary  with  the  degree 
of  the  disease  present. 

Palpation  very  commonly  reveals  a  prolapsed  movable  kidney  with 
enlargement  but  without  great  sensitiveness  when  compared  with  that 
found  in  infarct  and  acute  pyelitis.   Muscular  rigidity  is  rather  common. 

The  opposite  unaffected  kidney  may  be  more  palpable  than  normal 


87f>     IXFLA^f^fATlOXS  OF  REXAL  PELVIS  AXD  PAREXCHYMA 

due  to  (;oin])ensatiiijj:  liyportix)])hy  and  slightly  ttMidrr  diiriuii:  the  con- 
gesting which  accompanies  exacerbations. 

Ci/stoscopy  in  suppurative  acute  pi/elonephritis  respects  the  two  classes 
encountered,  namely  those  without  and  tliose  witli  injury  of  the  ureter 
with  hstuhi. 

Cystoscopy  in  acute  pyelonei)hritis  without  ureteral  fistula  reveals 
both  ureters  in  the  bladder  in  their  usual  position  and  discharging 
urine.  The  lu'cteric  moutli  of  the  unaffected  side  is,  of  course,  normal. 
]\Ieatoscopy  of  the  affected  side  shows  congestion,  edema,  comparative 
inactivity,  atony,  and  largely  duplicate  findings  of  the  meatus  of  pye- 
litis. If  ureteritis  by  extension  is  present,  these  changes  may  be 
extreme  and  profound. 

I'rinary  discharge  from  the  aH'ected  side  is  rhythmic  but  atonic. 
The  urine  is  ])us-bearing  in  rather  even  mixture  and  not  in  clumps, 
masses  or  strings,  and  emits  from  the  ureter  in  turl)id  pull's  exactly 
as  does  blood  in  red  clouds  during  hematuria. 

Ureteral  catheterism  permits  free  passage  without  obstruction,  easy 
evacuation  if  the  eye  of  the  catheter  does  not  plug.  The  more  recent 
and  mild  the  case  the  less  the  change  in  the  rhythm  and  efflux  of  the 
urine.  Old  advanced  cases  dribble  the  m'ine  from  the  catheter  without 
the  rhythm. 

Urinalysis  of  catheterized  urines  shows  most  marked  changes  dm'ing 
the  severe  symptoms.  The  excretion  of  the  diseased  kidney  is  usually 
acid,  albiuninous,  ])iu*ident  and  filled  with  every  cast  except  blood- 
casts,  but  most  especially  hyaline,  finely  and  coarsely  granular  epi- 
thelial and  pus-casts.  The  Bacillus  coli  communis  is  invariably  present 
either  in  pure  or  associated  culture.  Red  blood  cells  are  common. 
Fresh  blood  usuall>'  indicates  abrasions  by  the  catheter  and  hence  the 
wisdom  of  great  gentleness  in  the  examination. 

The  urine  from  the  normal  kidney  may  be  unchanged  or  that -of 
compensating  hypertrophy  Avith  congestion,  namely  a  few  casts,  slight 
and  temporary  albiunin,  renal  epithelia  and  the  like.  Fresh  blood  has 
the  same  indication,  as  just  stated. 

Functional  Renal  Tests. — In  suppurative  acute  pyelonephritis  with- 
out ureteral  fistula  are  shown  from  the  affected  side  delay  in  time  and 
decrease  in  quantity  in  all  the  important  tests  proportional  with  the 
duration  and  degree  of  the  disease.  The  unaffected  side  also  shows 
unfavorable  deficiency  during  exacerbations  due  to  the  congestion 
present  in  the  overworked  kidney. 

Suppurative  acute  pyelonephritis  with  ureteral  fistula  varies  from 
the  foregoing  picture  according  to  the  site  of  the  fistula,  as  in  the  skin, 
vagina  and  rectmn,  as  examples,  and  according  to  the  point  of  trans- 
plantation of  the  ureter  in  the  bladder. 

Physical  Examination. — Pyelonephritis  with  fistula  reveals  the 
ureteral  fistula  in  the  skin  by  its  surrounding  dermatitis,  in  the  vagina 
by  its  secondary  vaginitis,  and  in  the  rectum  by  its  consequent  proc- 
titis as  the  commonest  points  of  exit.  Other  than  these  facts  the  physi- 
cal examination  is  unchanged  from  that  in  other  cases  of  the  disease. 


SUPPURATIVE  ACUTE  PYELONEPHRITIS  877 

Cystoscopy  in  pyelonephritis  with  fistula  displays  the  normal  ureter 
discharging  urine  unchanged  in  rate,  rhythm,  quantity  or  quality. 
The  divided  lu-eter  shows  (;ommonly  no  urine  or  a  very  little  if  the 
fistula  does  not  evacuate  the  entire  output  in  the  unnatural  flircf.-tion. 
On  the  affected  side  there  is  no  ureteric  action  in  old(;r  cases  hut  there 
may  be  some  in  the  more  recent  cases,  especially  when  some  of  the 
urine  escapes  into  the  bladder. 

Ureteral  catheterism  is  unchanged  on  the  normal  side  but  on  the 
afi^ected  side  shows  a  sensitive  or  painful  obstruction  at  the  site  of  the 
wound  or  division  of  the  ureter  which  is  usually  in  the  vesical  third  of 
this  tube  not  far  from  the  bladder,  as  it  is  in  the  pelvic  operations  on 
women  that  accidents  to  the  ureter  occur. 

Diagnosis. — The  diagnosis  rests  on  the  usual  four  elements  of  diag- 
nosis in  urology,  namely,  history,  physical  examination,  laboratory 
investigation  and  cystoureteroscopy. 

The  history  should  be  carefully  taken  and  will  be  found  to  contain 
indefinite  and  ill-defined  facts  of  septic  absorption  as  previously 
described. 

The  physical  examination,  laboratory  investigation  and  cysto- 
ureteroscopy must  be  relied  upon  to  focus  attention  on  the  kidney, 
which  is  the  chief  fact  of  decision. 

Treatment.  —  Suppurative  acute  pyelonephritis  may  receive  both 
nonoperative  and  operative  treatment.  The  lesion  is  parench;^anatous 
as  well  as  pelvic  and  therefore  beyond  the  reach  of  such  measures  as 
internal  antiseptics  and  lavage  of  the  pelvis  which  may  alleviate  tem- 
porarily the  SATnptoms  due  to  the  ureteral  and  pelvic  conditions. 

Operative  measures  are  the  choice  and  are  summed  up  in  nephrec- 
tomy, in  examples  of  suppurative  diffuse  nephritis,  and  in  resection 
of  the  abscess  cavity  in  cases  of  focalized  suppurative  necrosis. 

Suppurative  pyelonephritis  secondary  to  divided  or  injured  ureter 
indicates  nephrectomy,  because  in  such  cases  the  infection  is  ascending 
from  the  bladder,  vagina,  rectum  or  skin,  according  to  the  point  of  outlet 
of  the  ureter.  Effort  to  repair  the  ureter  in  the  presence  of  suppura- 
tive ureteritis  and  changes  in  its  immediate  annexa  in  the  proximal 
segment  and  more  or  less  atony  through  disuse  in  the  distal  segment  is 
useless. 

Perinephritic  abscess  may  be  an  associated  or  a  secondary  condition, 
and  of  course  carries  its  own  indication  of  free  drainage  as  only  a  detail 
of  the  general  operative  intervention  on  the  kidney. 

The  aftertreatment  of  acute  pyelonephritis  concerns  the  building 
up  of  the  patient's  health,  the  usual  surgical  care  of  the  field,  and  very 
important,  the  cure  of  the  cystitis  which  frequently  is  present. 

Pyonephrosis. — Definition. — Pyonephrosis  comprises  literally  pus  in 
the  kidney  and  the  pelvis  as  the  sign  of  chronic  suppurative  infection. 

Pyonephrosis  is  analogous  to  hydronephrosis  with  infection,  pus 
production  and  nephritis  added. 

Etiology. — The  cause  of  pyonephrosis  involves  as  underlying  fac- 
tors ureteral  obstruction,  dilatation,  infection  and  suppuration.     The 


S7S     /.VFZ,.l.V.V.l77r).V.'^  OF  REXAL   PELVIS  AXD  PAREXrilYMA 

obstruction  may  be  situated  anywhere  in  the  urinary  tract  distal 
to  the  kidney,  exactly  as  in  hydronephrosis.  Antecedent  patholofjical 
conditions  may,  by  infection,  pass  over  into  pyonephrosis,  such  as 
hydroncj^hrosis.  chronic  pyelitis,  pyelonephritis,  abscess  of  the  kidney, 
supi)urati\'e  nephritis,  calculous  pyelitis  and  tumor  of  the  kidney. 

The  infecting  organism  is  the  Bacillus  coli  couKnuuis  in  pure  or 
associated  culture. 

Pathology. — The  lesions  reveal  in  a  ar>  ing  degree  the  site  and  signs 
of  obstruction,  dilatation  and  chronic  sui)])uration  of  the  pelvis  of  the 
kidney  and  then  of  the  parenchyma.    The  destruction  of  pressure  and 


Fig.  297. — Chronic  pyelonephritis,  inner  view.  Case  of  pyelonephritis  with  practical 
obliteration  of  kidney  substance  and  with  abscess  in  the  lower  pole.  Most  of  the  kidney 
substance  was  reduced  to  fat  as  at  A,  and  fat  or  fibrous  tissue  as  at  B.  In  the  lower 
pole  at  C  was  an  abscess  cavity  containing  the  Bacillus  coli  communis  and  the  Bacillus 
pyocyaneus.  The  kidney  was  densely  fixed  as  shown  by  the  strings  of  fat  and  adhesion 
at  D.     (.\uthor's  case.) 


suppuration  in  the  parenchyma  leads  to  all  degrees  from  mild  to  severe 
of  distortion,  deformity  and  atrophy  even  to  a  mere  shell  of  the  kidney 
substance  whose  typical  elements  are  largely  obliterated. 

Syndrome. — Pyonei)hrosis  shows  general  urinary  and  cystoscopic 
symptoms  variously  associated  mutually  or  secondary  to  antecedent 
conditions  such  as  calculus. 

The  general  subjective  symptoms  are  constitutional  and  reflex. 
They  are  slight  or  absent  in  mild  cases  and  marked  in  severe  cases  or 
during  absolute  obstruction  and  absorption  in  relapsing  cases.  Their 
character  is  generally  fever,  rigors,  nausea,  with  or  without  vomiting. 


SUPPURATIVE  ACUTE  PYEWNEPHRfTIS  870 

prostration  and  debility;  in  short,  all  the  persistent  chronic  symptoms 
of  low  septic  absorption. 

The  blood  count  is  that  commonly  seen  in  low  pus  cases. 

The  starting-point  of  the  disease  is  often  within  the  patient's  knowl- 
edge, as  urethra,  prostrate,  bladder,  ureter  and  ki(In(!y.  Marked  r(;nal 
signs  associated  with  pregnancy  are  very  common. 

Renal  symptoms  as  they  develop  are  indefinite  moderate  pain  in 
the  loin  behind  or  in  front,  with  exacerbations  during  motion  and 
acute  obstruction  and  with  relief  during  the  drainage  of  the  i)us  sac 
through  the  normal  channel.  Early  mild  cases  may  have  long  periods 
of  relief  during  good  drainage  of  the  pelvis,  while  later  older  cases 
always  have  some  symptoms  varying  in  intensity  with  the  obstruction. 

Palpation  shows  tenderness,  muscular  rigidity,  enlargement  or 
thickening  over  the  kidney  area,  which  is  usually  readily  verified  by 
bimanual  examination.  The  colon  is  commonly  found  crossing  the 
mass  percussion. 

Vesical  and  Urinary  Symptoms. — Chronic  cystitis  is  usually  present 
with  increased  frequency.  As  in  hydronephrosis  ureteral  and  urethral 
reflexes  are  usually  mild  or  absent. 

The  urine  of  pyonephrosis  is  a  chronic  pyuria  without  tubercle  bacilli 
but  with  pus  organisms,  especially  the  Bacillus  coli  communis.  In  the 
early  cases  pyuria  may  cease  during  acute  obstruction  and  thus  be 
absent  in  cystoscopy  alone,  provided,  of  course,  the  ureter  distal  to 
the  obstruction  is  still  healthy. 

Cystoscopy  and  Its  Adjuvants. — Cystoscopy  finds  a  bladder  which 
cleanses  easily  if  there  is  no  cystitis.  If  cystitis  is  present  it  is  confined 
to  the  immediate  annexa  of  the  affected  ureter  and  may  not  extend, 
and  thus  differs  from  tuberculosis  which  always  extends  and  not  infre- 
quently deposits  opposite  the  affected  lu-eter  as  well  as  around  it.  The 
bladder  of  pyonephrosis  is  not  irritable  in  any  high  degree,  which  is 
another  point  of  difference  from  vesical  tuberculosis. 

The  affected  ureter  may  be  normal  or  reveal  the  signs  of  chronic 
inflammation,  especially  after  the  ureter  has  become  involved  in  the 
lower  third.  Thus  the  meatus  is  patulous,  deformed  and  discharges 
pus  as  a  rule  unless  the  obstruction  is  complete,  when  there  will  be  no 
urine  and  only  pus  when  the  disease  has  advanced.  The  function  of  the 
ureter  is  weak,  decreased,  as  a  rule,  or  absent  in  total  obstruction. 
Relief  of  the  obstruction  increases  the  discharge  diu-ing  the  evacuation. 
The  urine  is  pus-laden  in  plugs,  strings  and  masses. 

Ureteral  Catheterism  is  absolutely  necessary.  The  passage  of  the 
catheter  is  usually  easy  unless  the  distortion  of  the  canal  is  great,  when 
the  thickening  and  irregularity  of  the  pass  may  really  prevent  com- 
plete catheterism.  Leakage  around  the  catheter  on  the  diseased  side 
is  common  on  account  of  these  conditions  and  the  dilatation  present. 
Plugs  of  pus  may  block  the  catheter,  which  should  be  freed  by  the  injec- 
tion of  fluid.  The  m-ine  as  it  flows  is  in  steady  drops  as  in  hydro- 
nephrosis and  not  in  spurts.  Residual  m"ine  is  frequently  found  in 
the  pelvis. 


SSO     IXFLAM}rATIOXS  OF  REXAL  PELVIS  AXD  PAREXCHYMA 

Treatment. — The  indications  are  always  operative  and  involve 
nephrectomy.  The  operation,  however,  should  never  be  done  without 
thorou^jh  knowledge  of  the  capaeity  of  the  normal  kidney  to  carry  on 
the  work  of  the  body. 

The  aftertreatnuMit  of  ])y()ne])hrosis  is  niucli  the  same  as  that  in 
pyelonephritis,  suri,ncal  attention  to  the  fii'ld,  buihUui;'  up  of  the  patient, 


Fig.  298. — Relation  of  l.\iiii>hatics  of  the  ureter  to  those  of  tlic  internal  Renitalia  of 
the  female  and  to  the  colon.  /,  lymphatics  from  colon  to  cortex  of  kidney;  2,  3  and  4< 
periKlomerular  boundary  zone  and  intertuhular  lymphatics  of  kidney  (Kimiita) ;  6, 
communication  of  periureteral  lymphatics;  6,  with  those  of  uterus,  tubes  and  ovaries. 
(Eisendrath  and  Sehultz.') 

restoration  of  the  bladder  and  attention  to  recovery  of  the  opposite 
kidney  by  the  usual  management  for  mild  renal  lesions. 

Conclusions. — 1 .  ^Yhile  infection  of  the  bladder  or  lower  iu"eter  may 
reach  the  renal  pelvis  or  the  kidney  either  by  way  of  the  liunen  of  the 
urinary  tract  or  by  way  of  the  mm-al  lymphatics,  experimental  and 


'  .Jour.  Am.  Med.  Assn.,  February  17,  1917,  p.  542. 


TUBERCULOSIS  OF  THE  KIDNEY  881 

clinical  evidence  indicates  that  complete  or  almost  f;omplete  obstruc- 
tion to  the  urinary  outflow  is  necessary  for  ascent  of  infection  by  way 
of  the  lumen  of  the  urinary  tract. 

2.  We  have  shown  experimentally  that  in  the  absence  of  complete 
obstruction  the  infection  may  and  does  pass  upward  from  the  bladder 
by  means  of  the  lymphatics  of  the  ureteral  wall. 

3.  Depending  on  the  virulence  of  the  organism  and  on  the  suscep- 
tibility of  the  host,  the  involvement  may  remain  limited  to  (1)  the 
bladder  and  ureter,  (2)  it  may  pass  upward  to  the  pelvis,  or  C-i)  it  may 
invade  the  renal  tissues.  When  the  kidney  itself  becomes  involved 
the  inflammatory  agent  is  carried  from  the  renal  pelvis  to  the  paren- 
chyma by  the  lymphatics  of  the  intertubular  and  perivascular  tissues. 

4.  In  the  human  being  the  lymphatic  network  constitutes  the  most 
important  path  of  ascending  infection  when  pyelonephritis  follows 
cystitis  not  associated  with  complete  obstruction  to  the  urinary  out- 
flow. 

5.  In  the  absence  of  cystitis  the  renal  pelvis  or  the  kidney  itself  may 
become  involved  by  the  transport  of  infection  from  the  pelvic  organs 
or  from  the  lower  intestinal  tract  through  the  anastomosing  lymphatic 
channels,  whiah  anatomic  study  has  shown  to  be  present. 

TUBERCULOSIS  OF  THE  KTONEY. 

Definition  and  Occurrence. — Infection  of  the  organ  with  the  Bacillus 
tuberculosis,  either  in  pure  or  mixed  culture,  and  showing  all  primary 
and  secondary  the  pathological  features  of  similar  infections  an^'W'here 
else  in  the  body,  constitutes  the  definition  of  this  disease.  Tubercu- 
losis of  the  kidney  occurs  in  the  early  cases  on  one  side,  as  a  rule,  but 
may  be  bilateral.  The  pure  infections  are  also  in  the  early  cases  while 
the  associated  infections  in  the  later  cases,  the  Bacillus  coli  communis, 
are  most  commonly  present. 

Tuberculous  autopsy  findings  show  renal  lesions  in  the  ratio  of 
1  in  10  cases,  while  the  clinical  frequency  among  surgical  renal  diseases 
is  according  to  most  operators  nearly  1  in  3  cases.  The  third  and 
fourth  decades  of  life  in  both  sexes  are  the  commonest  periods. 

Etiology. — Bacillus  tuberculosis  alone  in  the  first  stages  or  mixed 
with  pus  organisms  in  the  later  stages,  especially  Bacillus  coli  communis, 
is  the  exciting  organism.  The  avenue  of  infection  is  commonly  through 
the  blood  current,  from  the  presence  of  the  organism  in  the  system, 
with  or  without  clinical  manifestations,  the  former  comprising  the  so- 
called  primary  cases  and  the  latter  the  secondary  cases.  Tuberculous 
deposits  elsewhere  in  the  urogenital  tract  may  actually  or  seemingly 
precede  the  renal  manifestations  and  thus  comprise  another  class  of 
secondary  renal  cases.  It  is  difficult,  however,  to  see  how  tuberculosis 
of  the  lower  sexual  and  urinary  organs  such  as  the  bladder  and  testes 
may  infect  the  kidneys  excepting  through  the  blood  current. 

Subjective  Syndrome. — Tuberculosis  of  the  kidney  includes  systemic, 
reflex,  renal,  vesical  and  urinary  symptoms. 
56 


S82     IXFLAMMATIOXS  OF  REXAL  PELVIS  AXD  PAREXCHYMA 

The  subjective  and  ohjcctivo  syndromes  of  tuberculosis  of  the 
ki(hu\\  are  as  highly  variable  as  in  any  other  form  of  tubercidosis, 
hence  no  description  of  sym])toms  will  be  t\  pical  i)ut  oul\'  suggestive 
as  the  followhig  is  intended  to  be. 

The. systemic  sAinptoms  are  as  follows:  The  course  of  the  disease 
shows  slow, .chronic  cases  and  acute  fuhninatinji;  cases,  either  of  which 
may  be  greatly  changed  at  the  advent  of  mixed  infection.  Like  all 
tuberculosis,  the  invasion  is  usually  slow,  insidious  and  deceptive,  so 
that  many  months  or  several  years  pass  before  the  i)atient  suffers 


Fig.  21)',)  Fig.  300 

Fig.  298. — Miliary  tuberculosis  of  the  kidney.  Lobulations,  partly  anatomical  and 
partly  pathological,  outer  surface  tubercles  are  obvious.  The  ureter  is  densely  infiltrated 
and  ulcerated  at  its  isthmus  and  its  mucosa  filled  with  miliary  tubercles.  The  absence 
of  adhesions  of  the  kidney  to  its  annexa  is  remarkable.      (Author's  case.) 

Fig.  ,300. — Miliary  tuberculosis  of  the  Icidney.  Anterior  .surface  of  uncut  specimen. 
Fewer  miliary  tubercles  than  on  the  posterior  surface  are  sceji,  but  larfier  nodules  of 
early  abscess  with  tendency  toward  adhesions  are  distinguishable.     (Author's  case.) 


enough  to  seek  aid.  In  this  type,  when  the  suppurative  stage  begins, 
especially  with  mixed  infection,  precisely  as  in  tuberculosis  of  the  lungs, 
there  appear  sjinptoms  and  signs  of  septic  absorption,  chills,  afternoon 
fever,  nightsweats,  emaciation,  and  the  like.  If  the  renal  tuberculosis 
is  secondary  to  a  clinical  focus  elsewhere,  the  symptoms  of  the  latter 
are  simply  colored  by  those  of  the  former  ccmdition. 

Acute  fulminating  renal  tuberculosis  runs  its  course  hi  a  brief  period, 
especially  after  suppuration  begins.  It  is  in  some  cases  part  of  a  general 
tuberculous   infection. 

Subjecti\e  reflex  symptoms  are  nausea  and  \'omiting,  rarely  seen 


TUBERCULOSIS  OF  THE  KIDNEY 


883 


until  the  period  of  suppuration  is  present  and  advanced,     ivcflex  (Jis- 
turbance  of  the  bladder  is  discussed  under  urinary  symptoms. 

Subjective  renal  symptoms  are  usually  absent  ii)  th(;  earlier  ]>erio(ls 
but  always  present  in  the  later  stages.  At  first,  in  the  slow  chronic 
cases  few  definite  sensations  are  present,  the  question  of  the  patient 
being  chiefly  as  to  the  pus  in  the  urine,  and  thus  the  expectant  treat- 
ment of  urinary  antiseptics  and  vesical  irrigation  is  adoj)ted.  Later, 
when  the  disease  extends  down  the  ureter,  the  ])ain  greatly  increases 


Fig.  301  Fig.  302 

Fig.  301. — ^Tuberculosis  of  the  kidney.  Multiple  and  discrete  abscesses.  Inner 
surface.  Upper  half  of  kidney  totally  destroyed  by  multiple  confluent  abscesses.  Lower 
half  of  specimen  invaded  by  multiple  discrete  abscesses.  Pehds  infiltrated  -svith  tuber- 
culosis.    Normal  kidney  markings  absent.      (Author's  case.) 

Fig.  302. — Author's  case  of  tuberculosis  of  the  kidney,  after  incision,  interior  -\-iew. 
This  is  the  same  specimen  as  shown  in  Fig.  305.  The  kidney  has  been  di\-ided  from  pole 
to  pole  along  its  free  border  and  into  the  pelvis,  from  which  a  probe  is  passed  through 
the  urethra,  appearing  at  the  lower  edge  of  the  specimen.  Openings  into  numerous 
abscess  cavities  are  everywhere  apparent,  and  pus  is  seen  oozing  from  a  small  one  at 
the  upper  part  of  the  pehas.  Normal  kidney  substance  is  absent  and  many  tubercles 
may  be  seen  scattered  over  the  walls  of  the  abscesses,  especially  those  of  the  upper  pole. 


although  renal  colic  is  the  exception  unless  obstruction  through  a 
calculus  has  occurred. 

The  pain  is  in  the  renal  zone  of  the  affected  side,  dull  and  dragging, 
worse  during  congestion  of  exposure,  physical  exercise  and  menstrua- 
tion. Cramp-like  pains  accompany  the  passage  of  slugs  of  mucus  or 
pus.  The  normal  side  in  long-standing  cases  shows  the  hypertrophy 
and  congestion  of  double  duty  with  no  s^-mptoms  whatever  or  more 
than  those  of  the  affected  side  during  cono-estion. 


SS4     IXFLAMMATIOXS  OF  REXAL  PELVIS  AND  PARENCHYMA 


Fig.  303. — Author's  case  of  tuberculosis  of  the  kidney.  The  upper  half  of  the  organ 
has  been  deeply  invaded  and  nearly  destroyed  by  abscesses,  infiltration  and  scar  tissue. 
The  lower  half  of  the  organ  is  reasonably  normal  except  for  early  tul^ercles  in  the  pelvis 
and  calyces.  One  papilla  presents  in  the  middle  of  the  figure  with  an  ulcerating  tubercle 
on  it.  The  functional  test  of  this  organ  was  good,  although  decreased  and  tubercle 
bacilli  did  not  appear  in  the  urine  during  more  than  a  year  of  persistent  pyuria  but  no 
hematuria.    Indefinite  sensations  rather  than  pain  in  the  renal  zone  were  manifested. 


Fig.  304. — Author's  case  of  tuberculosis  of  kidneys  and  bladder.     The  tubercle  bacilli 
are  shown  in  many  characteristic  close  masses  and  bunches. 


TUBERCULOSTS  OF  THE  KIDNEY 


885 


■•jMjfriif**/ 

n 

^    ^^12 

fv^ 

*  ■^[..ii^jj^^^^^^B 

ng. 

^K^^r -^  2^SKfl^^ 

*-J^BF^^^^  '\vl 

.  9[||^B|||u  T^v^^ 

^4^...;^i^n..  U-j-^-t?i.^  J 

.Lh,  1   .. 

Fig.  305. — ^Author's  case  of  tuberculous  pyelonephritis  (inner  surface).  Same  speci- 
men as  Fig.  302.  Great  enlargement  of  the  organ  and  numerous  prominent  lobula- 
tions apparent,  also  adhesions  at  upper  pole.  Contracted  infiltrated  pelvis  and  very 
thick  enlarged  ureter  (fJ)  are  seen  in  the  central  picture.  (Referred  by  Dr.  Benjamin 
T.  Tilton.) 


Fig.  306. — Renal  tuberculosis  in  a  child.  Innumerable  tubercles,  multiple  abscesses 
and  profound  alteration  in  the  kidnej'  are  evident.  Bacillus  tuberculosis  and  BacUlus 
col i,  pyuria,  deficient  phenosulphonephthalein  test,  pain  and  cystitis,  marked  the  case 
amidst  good  bodily  health  without  emaciation.     Recovery.     (Author's  case.) 


SSf)     IXFLAMMATIOXS  OF  NEXAL  PELVTS  AXD  PAREXCIIYMA 

The  advent  of  suppuration  ])asses  a  mild  into  a  severe  case  in  almost 
every  instance. 

Acute  fulminatinj;  examples  of  the  disease  accentuate  the  lorei^oinii; 
general  course  of  the  pain  and  other  renal  sym])toms. 

Tuln'renlosis  associated  with  other  diseases  of  the  kidney  becomes 
an  added  factor  in  them,  such  as  lithiasis,  displacement,  mobility, 
])\elone])hrosis,  pyelonephritis,  as  examples,  and  ma.\-  sni)ersede  and 
mask  the  symptoms  of  the  antecedent  condition. 

Subjective  vesical  sym])toms  are  three:  ])ollakiuria,  or  increased 
frequency  of  urination,  dysuria,  or  j)ainful  lu-ination,  and  later,  tenes- 
mus. Of  these  three  cardinal  symptoms  the  first  is  ])resent  even  in 
mild  cases.  As  the  disease  proo;resses  the  pain  in  the  bladder  appears 
durhig  the  act  of  urination,  and  finall\-  tenesmus,  at  its  termination. 

The  cause  of  these  symptoms  is  the  irritation  of  the  tuberculous 
process,  first  in  the  kidney,  and  later,  by  extension,  hi  the  ureter  and 
bladder,  resultmg  in  positive  and  rapid  advance  of  suffering.  As  pre- 
viously stated,  nontuberculous  disease  in  the  same  parts  may  cause 
the  same  khid  but  less  degree  of  symptoms. 

Objective  urinary  symptoms  are  polyuria,  pyuria  and  hematuria. 
Of  these  three  cardmal  symptoms  the  first  is  always  present  even  in 
eatly  forms  and  regularly  accompanies  the  pollakiuria. 

P.M.iria,  meaning  macroscopic  quantities  of  pus,  observed  and 
reported  by  the  i)atient,  may  be  early  but  is  usually  later  in  appearance, 
but  in  microscopic  quantities  pus  is  an  early  and  im])ortant  element, 
as  later  discussed.  It  progresses  regularly  uj)  to  very  large  quantities, 
is  persistent  and  never  disappears  as  long  as  the  disease  is  untreated, 
and  its  sources  are  at  first  renal,  then  ureteral,  and  finally  vesical. 
The  largest  quantities  of  pus  are  from  the  bladder,  as  a  ride,  hence  the 
importance  of  ureteral  catheterization. 

Hematuria,  meaning  macroscopic  quantities  of  blood  described  by 
the  patient,  may  be  early  in  ulcers  of  the  kidney  or  pelvis,  eroding 
vessels.  This  is  rather  uncommon.  Blood  in  microscopic  (juantities 
is  always  present,  and  is  discussed  later. 

Objective  Syndrome  comprises  physical  examination,  cystoscopy 
with  its  adjuvants  and  urinalysis,  in  its  objective  features.  Every 
patient  with  this  flisease  is  a  law  unto  himself  and  iio  type  form  may 
be  described. 

Phj/siral  Fy.vaiuiitalioii. — rhysicalexamhiation  is  abdonunal  and  rectal 
or  vaginal. 

Bimanual  abdominal  examinaticm  with  the  bladder  empty  reveals 
on  the  affected  side  in  the  early  cases  Jiothing  definite,  in  the  later 
progressing  cases  renal  enlargement,  thickening,  nodulation  and 
tenderness,  which  still  later  may  be  traced  along  the  ureter  to  the 
bladder,  which  is  highly  irritable.  On  the  normal  side  there  may  be 
more  tenderness  thaji  on  the  diseased  side  through  the  congestion  of 
overwork,  especially  in  the  earlier  cases. 

Bimanual  rectal  and  vaginal  examination  with  the  bladder  full  in  the 
cases  with  ureteritis,  general  or  focalized  in  the  lower  third  of  the 


TUBERCULOSTS  OF  THE  KIDNEY  887 

canal,  develops  definite  thickeniiifi;  just  outside  the  bladder  wall. 
Earlier  cases  usually  give  negative;  findings.  Tuberculous  bladders 
are  irritable  to  touch,  whether  full  or  (;ni])ty.  (Cystoscopy  with  its 
adjuvants  in  tuberculosis  of  the  kicbiey  ijichides  eystoscoj)y,  irieato- 
scopy,  ureteral  catheterism,  fun(;tional  rcjial  tests,  radiography, 
bacteriology  and  animal  experimentation.  Cystoscopy  encounters  so 
highly  sensitive  a  viscus  as  to  require  general  or  spinal  anesthesia,  as 
local  anesthesia  almost  always  fails  because  the  irritability  may  not 
be  due  to  changes  in  the  bladder  but  to  exaggerated  reflex  influence 
from  the  kidney  and  the  ureter  above. 

The  clinical  and  cystoscopic  details  of-  tuberculosis  of  the  bladder 
are  fully  discussed  in  the  section  on  Ureteral  Meatoscopy  on  page  761, 
and  respect  the  annexa,  meatus,  ureteric  folds  and  interureteric  fold. 

In  the  early  cases  the  annexa  of  the  ureter  show  three  types  of 
change:  hyperemia  with  edema,  tubercle  formation  with  infiltration 
and  ulcers  with  granulations.  The  hyperemia  may  be  brushed  along 
the  floor  of  the  bladder  more  or  less  in  the  direction  of  the  urinary 
efflux  or  be  irregularly  daubed  about  the  meatus  like  dull  red  paint. 
The  edema  is  similarly  distributed  associated  with  the  hyperemia  or 
predominating  over  it. 

Tubercle  formation  with  injfiltrations  and  vesicles  is  the  next  step, 
at  first  few  discrete  and  scattered,  later  many  and  grouped  with 
vesicles  here  and  there  and  general  infiltration  of  the  mucosa  in  the 
same  regions. 

Ulcers  follow  breakdown  of  the  tubercles  and  then  granulations 
appear.  These  lesions  may  be  few  or  many,  large  or  small,  superficial 
or  deep,  and  are  usually  hemorrhagic. 

All  these  lesions  may  be  distributed  more  or  less  around  the  ureteric 
mouth  and  trigolium.  Occasionally  they  are  found  on  the  bladder 
wall  opposite  the  afi'ected  ureter,  where  in  the  empty  state  of  the  bladder 
the  mucous  membrane  rests  over  the  ureter.  Early  cases  show  the 
least  number,  M^hich  in  later  and  terminal  stages  may  involve  much 
or  even  all  the  bladder  wall. 

In  some  cases  ecchymoses  are  prominent  and  perhaps  predominant 
more  or  less  mterspersed  with  the  other  foregoing  lesions.  They  are  a 
little  more  apt  to  appear  in  the  more  rapid  forms. 

The  diseased  ureteric  mouth  itself  in  the  early  cases  shows  no  change 
whatever  or  only  lesions  in  association  with  a  given  type  in  its  annexa, 
as  just  described.  As  the  disease  progresses  from  the  kidney  as 
ureteritis  and  finally  reaches  the  vesical  third  of  the  ureter  and  as  the 
changes  in  the  bladder  increase  in  number,  variety  and  severity,  the 
ureteric  mouth  takes  on  distinctive  character,  embodying  thicken- 
ing, fixity,  distortion,  deformity,  retraction  and.  loss  of  muscular 
action.  "Golf-hole"  ureter  is  a  round,  patulous  mouth  without 
muscular  action.  "Tobacco-pouch"  ureter  is  a  patulous,  retracted, 
folded  mouth.  Other  forms  are  angular  and  irregular  in  outline.  All 
proceed  from  the  infiltration  and  thickening  and  are  very  common  in 
this  disease. 


888     IXFLAMMATIOXS  OF  REXAL  PELVIS  AXD  PAREXCHYMA 

The  Hernial  iiivtoric  mouth  in  early  cases  may  sliow  no  changes 
whatever  or  a  sympatlietic  edema  and  congestion  along  with  its  annexa; 
in  tlie  later  disease  when  tuberculous  ureteritis  on  the  affected  side 
and  trigonitis  are  present  with  extension  of  the  latter  over  to  the  normal 
side,  the  changes  in  the  mouth  may  seem  to  be  considerable  but  the 
absence  of  thickening  and  prominence  in  the  ureteric  fold  of  this  side 
usually  serve  to  distuiguish  the  comparative  simijlicity  and  vesical 
site  of  these  conditions. 

The  ureteric  fold  on  the  diseased  side  follows  nnich  the  same  law  as 
does  the  mouth  itself.  It  is,  therefore,  unail'ected  in  the  early  cases 
but  becomes  tliick,  prominent,  fixed  and  inelastic  in  the  later  cases. 
The  absence  of  these  conditions  in  the  normal  lU'cteric  fold  is  a  diag- 
nostic aid  in  locating  the  affected  kidney. 

Inasmuch  as  the  diagnosis  of  renal  tuberculosis  should  be  made  as 
early  as  possible  while  the  bladtler  is  relatively  not  diseased,  it  is  often 
possible  to  observe  the  difference  between  the  two  ureteric  folds  by 
mcreasing  or  decreasmg  the  distention  imder  the  field  of  the  cystoscope. 
This  manipidation  should  always  be  attempted. 

Urinary  discharge  shows  in  the  early  cases  no  naked-eye  variations 
from  the  normal  unless  increased  quantity,  decreased  color  and  difficult 
visibility  of  the  swirl.  In  the  later  cases  purulence  may  be  present 
and  distinguishable  in  the  swirl,  especially  if  there  is  no  cystitis  present. 
I  reteritis  and  deformity  of  the  meatus  commonly  show  slugs  and 
strings  of  mucus  and  pus  proceeding  from  or  clingmg  to  the  channel. 
Hemorrhagic  cases  during  the  period  of  bleeding  give  their  own  picture 
of  more  or  less  blood  from  the  meatus  in  the  presence  of  other  signs 
of  tuberculosis. 

The  rate  and  rhythm  of  the  urinary  discharge  from  the  meatus  in 
tuberculosis  of  the  kidney  do  not  vary  materially  from  those  seen  in 
other  pyogenous  renal  conditions,  such  as  pyelonephritis,  pyonephrosis, 
and  the  like.  No  description  other  than  that  already  gi\'en  under  these 
diseases  is  therefore  necessary. 

From  the  foregoing  facts  it  may  be  concluded  that  one  may  draw 
strong  inferences  as  to  the  kidney  affected  without  ureteral  catheterism 
or  urinary  segregation.  These  investigations  should  always  be  carried 
out  but  sometimes  fail  through  the  pathological  conditions  of  the  case 
or  the  experience  of  the  cystoscopist. 

Ureteral  Catheterism. — Preliminary  cleansing  of  the  bladder  should 
be  carried  out  as  thoroughly  as  possible  and  as  much  information 
obtained  at  a  single  investigation  as  practicable,  for  the  reason  that 
passage  of  the  catheter  is  not  without  some  danger  to  the  normal  ureter 
and  kidney.  The  final  step  of  the  procedure  is  lavage  of  the  pelvis 
and  ureter  with  bland  solutions  and  the  administration  of  urinary 
antiseptics  before  and  after  the  examination  in  every  case  possible, 
as  preventives  of  mfection. 

Early  cases  of  the  disease  may  usually  have  a  complete  examination 
at  one  sitting.  The  introduction  of  the  catheter  is  easy  on  the  affected 
side,  especially  if  gentleness  is  employed  and  no  traumatism  results. 


TUBERCULOSIS  OF  THE  KIDNEY 

because  ureteritis  has  not  yet  eliajiged  the  caliber  aiid  elasticity  of  the 
canal.  The  chief  point  is  to  select  a  full-sized  catheter  for  the  normal 
side,  G  F.  or  7  F.,  and  a  smaller  catheter  for  the  diseased  side,  5  F. 
This  detail  tends  to  prevent  leakage  from  the  normal  side  and  greater 
ease  of  passing  up  the  diseased  side. 

Later  cases  of  the  disease  will  have  a  ureter  still  pervious  to  urine 
but  so  thick,  tortuous,  inelastic  and  fixed  as  to  render  passage  of  the 
catheter  very  difficult  or  even  impossible  beyond  a  few  centimeters 
near  the  bladder.  Here  patulousness  may  cause  so  much  leaking  that 
one  has  to  rely  chiefly  on  the  urine  from  the  normal  side  and  that  from 
the  bladder  for  assisting  in  the  diagnosis,  hence  the  wisdom  of  having 
a  catheter  on  this  side,  which  so  far  as  possible  prevents  leakage.  It 
is  likewise  well  to  use  the  method  of  Casper,  of  injecting  indigo-carmin 
to  establish  the  presence  and  degree  of  the  leak. 

The  chief  anatomical  sites  of  difficulty  in  passing  the  catheter  along 
the  diseased  ureter  are  the  deformed  meatus  and  thickened  vesical 
segment,  and  the  point  where  the  ureter  crosses  the  brim  of  the  bony 
pelvis,  after  which  progress  along  the  canal  is  apt  to  be  much  less 
difficult. 

Urinalysis  is  the  laboratory  investigation  of  the  case.  The  diseased 
side  in  the  early  cases  shows  great  increase  in  quantity,  pale  color, 
faint  odor,  acid  reaction  and  low  specific  gravity,  similar  to  that  in 
chronic  diffuse  nephritis,  namely,  1010  or  thereabout.  Progressing 
cases  with  more  and  more  loss  of  kidney  function  gradually  de- 
crease the  quantity  and  have  neutral  or  alkaline  reaction.  Albumin 
appears  in  proportion  with  the  nephritis  and  the  pus,  in  early  cases 
little,  in  later  cases  much,  both  as  serum-albumin  and  nucleoalbiunin. 
Microscopically  the  tubercle  bacillus  is  always  present  although 
repeated  examination  alone  may  detect  it.  Pus  and  blood  in  micro- 
scopic quantity  are  constant,  especially  the  former.  Gross  amounts 
of  pus  appear  later  but  like  free  hemorrhage  may  be  a  peculiar,  early 
or  unexpected  symptom  at  any  time.  Desquamation  of  the  renal  and 
pelvoureteral  epithelium  gives  many  cells  more  or  less  degenerated. 
Casts  in  number  and  character  also  vary  with  the  nephritis,  pyuria 
and  hematuria;  in  the  early  cases  hyaline  and  granular  casts  pre- 
dominate, while  later  epithelial  and  pus  casts  may  appear.  In  every 
instance  the  greater  the  variety  of  findings  the  older,  more  advanced 
and  destructive  the  disease. 

The  normal  kidney  in  the  early  cases  shows  little  or  no  variation 
from  the  normal  quantity  of  urine,  while  the  diseased  kidney  is  still 
doing  almost  full  duty.  Later  on,  when  the  latter  is  failing,  the  normal 
kidney  shows  an  increased  output  in  compensation,  of  rather  pale  color, 
acid  reaction  and  normal  specific  gravity  which  tends  to  fall  as  the 
fluid  increases  but  never  as  low  as  on  the  diseased  side.  Albimiin  is 
usually  absent  excepting  temporarily  durmg  congestion.  INIicroscopic- 
ally  the  normal  kidney  shows  no  tubercle  bacilli  and  only  durmg  tem- 
porary overwork,  any  casts.  At  such  times  there  may  be  present 
hyaline  casts,  moderately  degenerated  epithelium  from  kidney,  pelvis 


890   I^'FLA^[^fATIO^'S  or  rexal  pelvis  axd  parexciiyma 

ami  iiivtrr,  a  tVw  Icukorytos  and  red  IjIoikI  ci-lls  hut  im  ])iis  Ix-yond  a 
few  scattered  cells. 

FuncHonal  Tetif.s  vary  with  the  actual  ])cri()d  and  activity  of  the 
disease  and  with  the  ])rcscnc{>  or  ahsi'ucc  of  tcnii)orai\\  hy])ertcnsion 
on  the  normal  orjiian. 

In  the  early  cases  there  is  not  a  j;reat  divergence  from  the  normal. 
In  the  later  cases,  however,  the  diirerence  hicreases  more  or  less  ])arallel 
\\\x\\  the  other  sijins,  such  as  pus,  nei)hritis,  blood,  and  the  like.  In 
the  a\'era,t;;e  case  the  normal  kidne>'  ])erforms  full  or  excessive  function 
excei)tinji;  during  ])erio(ls  of  congestion  when  the  findings  will  also 
lapse  below*  the  standard. 

Indigo-carniin  test  shows  on  the  affected  side  in  early  lesions  i)ale 
blue  or  yellow-green  color  in  from  fifteen  to  twenty  minutes.  In  the 
later  stages  there  will  be  no  reaction  whatever  or  a  very  long  delay. 
It  is  well  to  acidify  such  lU'incs  because  sometimes  the  absence  of  color 
is  a  decolorization  which  is  restored  by  changing  the  reaction  from 
neutral  or  alkaline. 

The  normal  kidney  in  the  early  cases  discharges  the  usual  blue  color 
hi  from  five  to  ten  minutes  and  in  the  later  stages  in  from  ten  to  twenty 
muuites.  In  other  words,  during  the  stage  of  congestion,  it  behaves 
like  the  diseased  kidney  in  the  early  stages  by  delaying  the  excretion 
but  without,  however,  the  tubercle  bacillus  and  other  signs  of  infection. 

Plilondziii  test  develops  on  the  affected  side,  in  the  early  i)eriods,  a 
delay  of  about  three  times  the  normal,  namely,  up  to  thirty  or  forty 
minutes,  while  in  the  advanced  stage  there  may  be  no  reaction  at  all 
or  only  after  sixty  minutes.  The  normal  kidney  in  the  early  days  show^s 
no  change  from  the  usual  ten  or  fifteen  minutes,  which  in  the  later 
developments  advances  to  ten  or  twenty  mimites,  This  test,  therefore, 
does  not  show  quite  as  w  ide  a  divergence  as  does  the  indigo-carmin. 

Phenolsulphonephtlialein  test  displays  for  the  affected  side  in  the 
onset  of  the  disease  only  slight  delay  in  time  and  moderate  decrease 
in  the  total  excretion  during  the  first  thirty  to  sixty  mijuites.  In  the 
more  destructive  period  the  delay  is  longer  and  the  loss  in  quantity 
much  greater  during  these  periods,  so  that  some  cases  show  less  than 
10  or  even  5  per  cent,  excretion. 

The  normal  kidney  in  the  corres])onding  ])cri()fls  of  the  disease  gives 
no  change  whatever,  and  even  in  the  later  ])cri()ds  less  change  in  time 
but  considerable  hi  the  quantity  excreted  in  the  first  hour,  especially 
when  congestion  is  present. 

This  test,  therefore,  is  somewhat  parallel  with  the  indigo-carmin  in 
its  findings  as  to  the  time  of  the  api)carance  of  the  dye,  and  being  also 
quantitative  is  to  be  preferred  to  the  indigo-carmin  when  both  cannot 
be  used. 

Radiography. — Radiography  in  tuberculosis  of  the  kidney  includes 
.r-ray  pliotogra])hy  of  the  entire  genito-urinary  tract  with  and  without 
the  injection  of  fluids  impervious  to  these  rays  into  the  bladder,  ureter 
and  pelvis  of  the  kidney.  The  former  will  frequently  reveal  changes 
in  the  size  and  form  of  the  kidney,  pelvic  and  ureteral  shadows,  but  the 


TUBERCULOSIS  OF  THE  KIDNEY  891 

latter,  when  practicable,  will  give  the  best  evidence  of  all  the;  changes 
previously  spoken  of. 

Bacteriology. — Bacteriology  aims  to -display  the  tubercle  bacillus, 
which  is  always  })resent  although  at  times  in  small  jnimbcrs  and  very 
difficult  to  find  in  the  early  stages  but  usuall}'  easier  jji  the  later  stages. 
Several  specimens,  preferably  twenty-four-hour  collections  of  urine, 
are  often  necessary  before  the  organism  is  isolated.  In  the  later  periods, 
when  pyuria  is  prominent,  mixed  hifectioji  is  very  common,  the  asso- 
ciating organism  being  the  Bacillus  coli  communis.  Animal  experi- 
mentation involves  the  injection  of  the  guinea-pig  under  the  most  strict 
antiseptic  precautions  with  the  infected  urine  and  then  killing  and 
examining  the  pig  in  from  five  to  eight  weeks  for  lesions  of  the  disease. 

The  best  usage  is  regarded  as  the  injection  of  three  pigs,  respectively, 
with  the  urines  from  the  normal  kidney,  the  diseased  kidney  and  the 
bladder.  If  only  the  last  injection  is  positive  the  second  must  be 
repeated.  As  a  rule,  however,  only  the  first-named  injection  is  negative. 
This  test  is  regarded  as  the  most  delicate  and  reliable  when  properly 
done. 

Diagnosis. — The  diagnosis  of  tuberculosis  of  the  kidney  rests  on  the 
following  cardinal  symptoms,  which  are  apt  to  appear  more  or  less  in 
the  following  sequence:  polyuria;  persistent  intractable  pyuria  not 
corrected  by  bladder  irrigation;  diurnal  and  nocturnal  dysuria;  irri- 
tability, incontinence,  and  then  contracture  of  the  bladder;  definite 
signs  of  tuberculosis  through  cystoscopy,  catheterization  of  the  ureters 
and  their  adjuvants;  and  last  and  finally,  tubercle  bacilli  in  the  urine 
demonstrated  by  bacteriology  and  animal  injection. 

It  is  most  important  to  remember  that  cystoscopic  suggestion  of 
tuberculosis  of  the  bladder  may  show  seemingly  clear  urine  from  both 
kidneys,  hence  ureteral  catheterism  is  absolutely  necessary  to  locate 
the  diseased  kidney  or  to  rule  out  the  kidneys  as  the  source  of  the  vesical 
condition. 

Differential  Diagnosis. — Until  the  tubercle  bacilli  appear,  the  early 
symptoms  of  renal  tuberculosis  resemble  several  of  the  other  surgical 
renal  conditions.  The  presence  of  this  organism  is  therefore  the  absolute 
and  final  distinction.  The  diseases  which  may  lead  to  error  in  diag- 
nosis are  the  other  pyogenic  infections  of  the  urogenital  tract,  such 
as  non-tuberculous  cystitis,  pyelitis,  pyelonephritis,  pyonephrosis, 
nephrolithiasis,  renal  neoplasm  and  renal  varix. 

In  all  these  conditions  the  early  stages  are  the  periods  most  likely  to 
be  confused  with  the  onset  of  renal  tuberculosis,  which  should  properly 
be  recognized  before  the  stages  of  macroscopic  pus  or  blood  in  the  urme. 

Nontuberculous  differs  from  tuberculous  cystitis  in  usually  giving  a 
history  of  exciting  cause,  rapid,  severe  onset,  brief  course  with  prompt 
benefit  from  treatment.  The  cystitis  is  generalized  rather  than  local- 
ized, hence  produces  much  pus  at  once  which  washes  from  the  bladder 
with  great  difficulty  so  that  a  thorough  cystoscopy  is  sometimes 
defeated  by  the  formation  of  the  pus  in  the  distending  mediimi.  The 
infecting  organism  is  never  the  tubercle  bacillus  but  either  the  Bacillus 


802     IXFLAMMArinx.^  OF  REXAL  PETAJS  A XI)  PARENCHYMA 

coli  conmumis,  goiiococcus,  Staphylococcus  or  Streptococcus  pyogenes. 
]\Iucli  albumin  ilue  to  the  pus  is  present  and  the  cystoscopic  i)icture  is 
cliaracteristic,  as  already  described.  Unless  nephritis  is  an  antecedent 
condition  there  are  never  any  signs  of  it  and  there  are  no  ()])jective 
signs  ui  the  kidney  zone  of  early  hivolvenient. 

Pyelitis,  pyelonephritis  and  pyonephrosis  are  somewhat  similar  in  their 
owTi  onset,  course  and  symptoms.  They  alike  give  acute  appearance 
of  fever  and  more  or  less  septic  absorption  with  characteristic  fe\er. 
The  bladder  is  not  so  irritable,  intolerant  and  later  contracted,  and 
shows  no  tubercle  deposits  but  rather  localized  suppurative  cystitis. 
The  ureters  are  not  palpable  on  bimanual  examination  and  the  kidney 
region  shows  subjecti^•e  and  objecti\'e  evidence  of  inflammatory  or  sup- 
purative process  of  more  rapid  type  than  tuberculosis.  The  infecting 
organism  is  the  Bacillus  coli  communis,  associated  with  other  pyogenic 
germs  or  alone.  TJie  most  difficult  cases  are  those  which  later  become 
tuberculous  from  foci  elsewhere  in  the  body  or  adventitiously,  hence  the 
necessity  of  repeated  faithful  tests  for  the  Bacillus  tuberculosis. 

NephroUtkia,sis  commoidy  affords  a  history  of  gravel,  stone  or  colic, 
of  vesical  symptoms  absent  during  periods  of  rest  and  present  during 
attacks  of  colic  or  renal  irritability.  Hematuria  is  earlier  and  usually 
more  severe  than  in  tuberculosis  and  the  p>'uria,  while  persistent,  is  less 
prominent.  Pyonephrosis  with  a  calculus  gives  a  more  marked  and 
complex  picture.  Cystoscopy  and  ureteral  catheterism,  especially  with 
the  waxed-tip  catheters  and  filiform  guides  combined  with  radiography,, 
which  should  never  be  omitted,  will  establish  the  diagnosis.  The  other 
pyogenic  organisms  and  not  the  Bacillus  tul)erculosis  are  present,  unless 
the  latter  has  been  implanted  on  the  other  process,  hence  this  organism 
must  be  excluded  by  repeated  careful  tests. 

Renal  neoplasm  and  renal  varix  develop  rapid  bleeding  in  the  early 
stages  from  congestion  of  the  tortuous  vessels  rather  than  from  ulcera- 
tion which  is  the  source  of  the  same  character  of  bleeding  in  tuberculosis. 
They  also  show  no  pollakiuria  excepting  while  the  blood  is  in  the 
bladder.  The  tubercle  bacillus  should  also  be  looked  for  in  the  way 
just  stated. 

Treatment. — Nonoperative  measures  are  available  only  in  the  early 
cases  without  severe  sAinptoms  and  are  the  standard  forced  feedhig, 
hygiene  and  climate.  Such  measures  have  largely  been  abandoned 
because  it  has  been  shown  that  even  when  tuberculous  kidneys  recover 
they  may  at  any  time  light  up  again  in  much  more  intense  and  danger- 
ous degree  of  the  process. 

Operative  means  are  therefore  preferred  aiid  follow  these  principles: 

With  the  normal  kidney  in  full  function  the  diseased  kidney  should 
be  removed. 

With  the  normal  kidney  in  nearly  full  function  and  with  the  dis- 
eased kidney  largely  destroyed  and  the  origin  of  septic  absorption, 
nephrectomy  should  be  done,  and  usually  promises  well, 

W^ith  both  kidneys  diseased  but  one  much  more  advanced  than  the 
other  and  w ith  septic  symptoms  ])rominent,  the  more  imolved  organ 


//  YD  RO  NEPfl  ROS/S 


893 


shoiilcl  be  exposed,   incisc^d  uiu]   (Iraijiefl,   hikI  later  rernovcfl   if  the 
opposite  kidney  recovers  through  relief  of  the  septic  poisoning. 

The  aftertreatment  comprises  the  proper  medical  and  surgical 
management  of  the  patient  and  field  and  in  addition  suitable  care  of 
the  bladder  which  not  hifrequently  promptly  and  fully  recovers  after 
removal  of  the  source  of  infection. 

HYDRONEPHROSIS. 

Definition.— Hydronephrosis  may  be  defined  as  collection  of  urine  in 
the  pelvis  of  the  kidney  due  to  distal  obstruction,  usually  incomplete 
and  chronic,  and  less  commonly  complete  and  recurrent,  and  character- 
ized by  dilatation  and  deformity  of  the  renal  pelvis  and  by  recurrent 


Tti 


Figs.  307  and  308. — Pyelograms  of  hydronephrosis  Tvith  mobility.     (Fowler.i) 
Fig.  307. — Patient  recumbent.     Right  kidney  I5  inches  below  normal  position.     No 
inflammatory  indications.     Pelvis  and  ureter  normal.     Ureteral  catheter  not  into  the 
kidney.     Ureter  is  curled  a  half  turn  at  end  of  catheter,  which  met  obstruction  25  cm. 
from  mouth  of  urethra. 

Fig.  308. — Same  patient  standing.  Kidney  entirely 'W'ithin  pelvis.  Rotated  on  antero- 
posterior axis  so  that  outer  border  is  facing  downward.  The  kink  in  the  ureter  is  opposite 
IV  lumbar  vertebra.  Diagnosis:  right-side  intermittent  hydronephrosis  without  patho- 
logical changes. 

retention  and  evacuation  and  more  or  less  tendency  toward  decompo- 
sition of  urine  and  infection,  but  not  in  the  degrees  seen  in  pyelitis. 

Such  definition  of  liydronephrosis  is  aimed  to  exclude  deformity  of 
the  renal  pelvis  secondary  to  suppurative  inflammation  of  the  kidney 


1  Tr.  Am.  Urol.  Assn.,  1912,  xi,  186. 


S94     lyFLAMMATIOXS  OF  REXAL  PELVIS  AM)  PARE.WIIYMA 

or  its  pelvis,   tuberculosis,   neoplasm,   and    with   certain   exceptions, 
lithiasis. 

Varieties  and  Etiology. — The  underlying'  basis  is  ureteral  obstruction, 
chronic  and  incomplete,  with  more  or  less  persistent  symi)toms,  or  recur- 
rent and  complete,  with  more  or  less  u\termittent  syndrome.  In  other 
words,  chronic  inci)m])lete  obstruction  never  totally  ])revents  some 
drainaj:;e  throuj,di  the  ureter,  while,  on  the  other  hand,  recurrcjit  com- 
plete obstruction  shows  periods  when  the  ureter  is  in  virtually  normal 
condition  so  far  as  drainap:e  is  concerned.  Both  forms  may  have  acute 
attacks  of  symptoms  due  to  the  tem])orary  and  more  positive  action  of 
the  underlyinji  cause  of  the  obstruction  or  to  such  additional  factors 
as  congestion  or  increased  hifection.  The  intermittent  type  of  the 
disease  has  the  more  positive  degrees  of  acute  attacks. 


Fig.  309. — Repair  of  ureteral  oKstructions  in  hydronephrosis.  The  first  diagram 
shows  the  kidney  in  position:  the  second,  the  incision  made  in  the  pelvis  and  ureter;  the 
third,  the  closure  of  this  incision  and  its  result  on  the  drainage  of  the  pelvis.     (Kelly.') 


The  causal  factors  are  identical  with  those  of  ureteral  obstruction 
and  stricture.  The  intermittent  type  appears  hi  the  third  decade  of 
life  and  is  frecjuent  in  women  through  pregnaiicy.  Congenital  elements 
at  work  are  various  degrees  of  maldevelopment,  displacement  or 
anomaly  of  the  urinary  organ — kidneys,  ureters,  bladder  or  urethra 
in  both  sexes,  and  prostate  in  the  male.  The  outcome  of  these  are 
torsions,  kiiiks  and  valves  of  the  lU'eter.  High  or  lateral  implantation 
of  the  ureter  into  the  bladder  may  act  similarly.  Supernumerary  or 
anomalous  bloodvessels  of  the  renal  or  lumbar  group  may  cross  and 
obstruct  the  ureter.  Pregnancy  and  other  factors  in  mo^'able  kidneys 
are  on  the  border  line  between  congenital  and  acquired  forms. 

1  Tr.  Am.  Urol.  Assn.,  1909,  iii,  375. 


IfYDnONEI'IlROSIS 


895 


Acquired  causes  of  hydronephrosis  are  usually  accepted  as:  Tnnam- 
matory  or  traumatic  ureteric  stricture,  })(;ri ureteral  iriHarnmatory 
infiltration,  peritonitic  bands  and  adhesions,  })ends  and  twists  of  the 
ureter  throufijh  infiaTnination  or  injury,  migratory  lithiasis  with  recur- 
rent impaction,  and  ])fessure  by  tumor  in  the  bladder  or  ureter  or  the 
annexa,  most  esjx'cially  the  pressure  of  j)refi;]iancy. 

The  site  of  obstruction  in  hydronephrosis  is  at  the  isthmus  where 
ureter  and  i)elvis  join  and  where  muscle  fibers  form  a  kind  of  sphijicter. 


Fig.  310. — Hydronephrotic  kidney  surgically  removed.  The  kidney  is  lobulated 
and  the  pelvis  composed  of  an  intrarenal  and  extrarenal  pouch.  A  vein  accompanied 
by  a  retracted  artery  crosses  the  ureter  at  its  juncture  with  the  pelvis.  (Legueu,  Papin, 
Maingot.i) 


Subjective  Syndrome. — The  chief  s^^Ilptoms  are  sensory  and  urinary. 
The  chief  complaint  is  indefinite  discomfort  interrupted  by  periods  of 
positive  pain.  The  location  of  these  sensations  is  m  the  affected  kidney 
zone,  namely,  hypochondrium  in  front  and  behind  m  the  costovertebral 
angle  or  iliocostal  space;  maximum  durmg  the  attack  of  acute  reten- 
tion ;  with  no  definite  direction  or  point  of  reference  through  the  slow 
distention;  excited  by  agitation  of  exercise  or  travel;  relieved  by  rest 

1  Log.  cit 


S96     IXFLAMMATIOXS  OF  REXAL  PELVIS  AXD  PAREXClIYMA 

in  bed  and  evacuation  of  the  baeked-up  lu-ine;  occurring;  at  varying 
intervals  usually  longer  in  the  milder  cases  with  tendency  to  shortening 
as  the  disease  becomes  more  deeply  seated;  constant  and  persistent 
as  discomfort  but  as  true  pain  only  during  acute  attacks;  intermittent 
usually  absolutely  for  the  true  pain  during  good  drainage  but  only 
relatively  for  the  intletinite  discomfort;  accom])anied  by  sense  of  tume- 
faction on  the  att'ected  side  and  by  rellex  signs  such  as  anorexia  and 
nausea,  sometimes  by  vomiting  and  imlike  renal  calculus  rarely  by 
syncope,  frequency  of  micturition,  ])olyuria,  oliguria  or  anuria,  but  like 
renal  calculus  by  ])rostration  and  exhaustion  due  to  the  greater  persist- 
ence of  the  attack,  the  urinary  retention  and  the  septic  absorption. 


Fiu.  311. — Section  of  the  same  kidnej-  shown  in  Fig.  310.  The  parenchyma  is  reduced 
to  a  narrow  strip  hardly  a  centimeter  wide.  All  the  pouches  visible  in  the  undivided 
specimen  together  with  others  are  apparent. 

The  foregoing  outlme  is  reasonably  typical  of  intermittent  hydro- 
nephrosis. 

Chronic  remittent  hydronephrosis  shows  similar  s^Tnptoms  always 
present  and  persistent  with  periods  of  exacerbation  less  marked,  how- 
ever, than  the  true  attacks  in  tlie  other  form . 

Fever  with  or  without  chilliness  rather  than  true  chills  is  the  regular 
accompaniment  of  attacks  in  both  forms  due  to  the  urinary  retention 
and  the  moderate  septic  absorption. 

The  subjective  urinary  sjTuptoms  are  usually  slight  except  in  marked 
cases;  The  total  retention  is  usually  a  few  ounces,  less  than  a  half  pint, 
and  slow  in  its  development  and  likewise,  as  a  rule,  in  its  evacuation 


//  YDRONEI'IIh'OSIS 


897 


by  Nature.  These  facts  are  due  to  the  rather  slow  establishment  of 
total  obstruction  in  both  the  intermittent  and  n^mittent  forms.  I )uring 
attacks  the  opposite  kidney  is  temporarily  doing  double  duty  and  there- 
fore in  a  state  of  congestion  with  relatively  decreased  output  of  urine, 
in  common  experience.  Large  sacs  with  copious  retention  and  more 
or  less  sudden  evacuation  are  extremely  rare. 


Fig.  312. — Enormous  hydronephrotic  mass.  The  specimen  consists  of  two  kidnej-s; 
the  lower  is  dilated  into  a  very  large  pouch  and  the  upper,  which  is  small,  has  a  separate 
ureter  and  has  undergone  slight  enlargement.     (Legueu,  Papin  and  Maingot.) 

When  the  attack  is  over,  the  obstruction  open,  the  evacuation  estab- 
lished, and  the  normal  kidney  relieved  of  overwork,  temporary  poly- 
uria may  appear  through  the  physical  presence  of  accimiulated  urine 
or  through  reflex  sources.  As  in  lithiasis  so  in  hydronephrosis,  pohiiria 
may  occur  through  reflex  irritation  alone. 

Frequency  of  urmation  through  irritation  of  the  bladder  is  very 
uncommon;  in  fact,  Pilcher  claims  that  septic  infarct  of  the  kidney  and 
attacks  of  intermittent  hydronephrosis  are  the  only  acute  renal  condi- 
tions not  accompanied  by  increased  frequency  of  micturition. 

Objective  Syndrome. — Hydronephrosis  includes  features  on  urinalysis 
of  mixed  and  separated  urmes  and  cystoscopy  with  its  adjuvants. 
57 


898     IXFLAMMATIOXS  OF  RENAL  PELVIS  AND  PARENCHYMA 

Physical  E.ra7niuation. — Inspection  is  negative  except  in  marked 
cases  which  cjive  less  mobility  on  the  atVected  side. 

Palpation  ^e^•eals  com])arative  absence  of  the  reflex  rigidity  of  the 
rectus.  During  the  attack  with  the  sac  filled  there  is  commonly  a 
distinct  elastic  tender  mass  with  the  general  impression  of  cyst.  Defi- 
nite fluctuation  appears  with  a  mass  large  enough  to  permit  its  classic 
determhiation  between  the  two  hands.  Between  the  attacks  in  marked 
cases  tliickening  of  the  sac,  displacement  of  the  kidney,  and  similar 
factors  may  be  })alpable. 

Urinalyds  of  the  Mixed  and  Catheterized  Urines. — The  vesical  or 
mixed  urine  is  of  little  Aalue  beyond  establishing  the  signs  of  moderately 
purulcjit  urine  abimdant  in  renal  elements.  !Se])arated  catheterized 
specimens,  however,  should  be  carefully  analyzed.  The  specimen  from 
the  normal  or  less  afl'ected  side  shows  only  the  albuminuria,  decrease 
of  urea  and  other  salts,  and  microscopic  elements  of  congested 
kidney.  ^Yhereas  the  urhic  from  the  hydronephrotic  kidne>'  is  turbid 
with  mucus,  some  pus  and  phosphates,  alkaline  and  foul  from  early 
decomposition  and  of  diverse  specific  gravity  according  to  the  efficiency 
of  the  kidney  excretion.  The  pus  and  all  other  signs  in  this  specimen 
vary  in  direct  proportion  with  the  duration  and  severity'  of  the  disease. 

Cystoscopy  and  Its  Adjuvants  are  essential  and  the  real  crux  of  the 
diagnosis  and  treatment,  and  include  cystoscopy,  ureteral  meatoscopy, 
ureteral  catheterism,  fmictional  tests,  measurement  and  deductions 
of  the  capacity  of  the  renal  pelvis  and  radiography. 

Cystoscopy  and  ureteral  meatoscopy  commonly  reveal  a  normal 
bladder  as  a  whole  except  for  deformity  or  displacement  of  the  affected 
ureter.  The  mouths  of  both  ureters  may  be  normal  or  that  of  the 
affected  side  implanted  high  or  laterally,  or  possess  a  deformed  and 
elongated  meatus.  The  meatus  of  lithiasis — a  common  basis  of  hydro- 
nephrosis— is  typical  and  has  been  described.  The  changed  function 
of  the  affected  kidney  usually  disorders  the  muscular  action  of  the 
ureter  so  that  the  tone  is  decreased  and  the  urine  dribbles  rather  than 
periodically  spurts.  During  acute  retention  there  may  be  no  action  of 
the  ureter  muscularly,  certainly  no  outflow  of  the  excretion.  The  urine 
as  it  is  delivered  from  the  affected  side  may  be  seen  to  be  colored  with 
mucus  and  pus  while  that  from  the  normal  side  has  less  or  no  pus. 

Ureteral  Catheterism. — Meatal  malformation  and  displacement  may 
make  penetration  of  the  ureter  difficidt.  In  other  cases  the  ease 
of  entrance  of  the  catheter  varies  with  the  cause.  Once  entered,  the 
passage  of  the  catheter  is  usually  not  difficult,  especially  if  one  of 
medium  caliber  in  preference  to  full  size  is  employed. 

Congenital  deformity  of  the  ureter  is  usually  at  the  jimction  with  the 
pelvis  about  25  cm.  from  the  meatus  and  is  easy  to  pass  with  deliber- 
ation in  order  to  allay  any  spasm,  likewise  acquired  kinks,  twists  or 
valves,  narrowings  of  the  canal  by  uiflammatory  or  traumatic  strictures, 
pressure  from  peritoneal  inflammatory  deposits,  bands  and  adhesions, 
or  from  peri-ureteral  inflammation,  or  from  tumors,  or  from  aberrant 
bloodvessels.    Gentleness,  deliberation  and  care  should  rule. 


nYDRONEPHROSTS  899 

Lithiasis  in  the  ureteropelvic  juncture  actinji;  as  a  ball  in  a  valve  is 
usually  found  a  little  higher  up,  say  30  cm.  The  catheter  reaches  the 
stone,  is  blocked,  begins  to  displace  the  stone  with  pain,  hesitates,  and 
then  passes  the  obstruction  more  or  less  suddenly,  not  uncommonly 
with  pain. 

Entrance  into  the  renal  pelvis  is  shown  much  as  is  entrance  into  the 
urinary  bladder,  through  a  stricture  with  a  small  catheter,  by  flow  of 
the  urine  in  drops  steadily  and  without  periodic  muscular  action.  The 
quality  of  the  urine  varies  with  the  lesion  and  the  quantity  with  the 
size  of  the  sac.  The  eye  of  the  catheter  at  first  reaches  the  upper  and 
clearer  level  of  the  urine  so  that  the  first  outflow  is  of  reasonably  good- 
looking  urine.  As  the  deeper  levels  are  reached,  the  sediment  begins 
to  appear  as  pus,  mucus,  phosphates,  and  the  like.  Sometimes  after  a 
little  sediment  has  come  away,  the  catheter  becomes  blocked  and 
lavage  of  the  pelvis  must  be  instituted  in  order  to  evacuate  the 
contents  thoroughly. 

Functional  Renal  Tests  depend  on  the  lesion  whose  essence  is  that  the 
affected  kidney  is  in  a  state  of  chronic  obstruction  with  exacerbations 
in  the  remittent  type  or  of  reasonably  free  drainage  with  attacks  of 
acute  temporary  total  obstruction  in  the  intermittent  type.  During 
such  exacerbation  or  attacks,  therefore,  the  normal  kidney  is  doing 
extra  work  and  will  show  on  urinalysis  albmnin,  decreased  urea  and 
other  elements,  and  according  to  Albarran,  Braasch,  Pilcher  and  other 
observers,  delay  in  the  phloridzin  test. 

The  phenolsulphonephthalein  test  is  likewise  altered  in  the  time  and 
quantitative  excretion  of  the  dye. 

The  abnormal  kidney  necessarily  shows  profound  changes  in  all  the 
tests,  especially  during  the  attack,  because  there  is  no  flow  of  urine 
into  the  bladder. 

In  the  interval  between  the  attacks,  both  kidneys  in  the  intermittent 
form  may  more  nearly  approach  the  normal  output  while  in  the 
remittent  form  the  difference  between  the  two  sides  may  be  still  great. 
These  divergences  are  most  marked  in  advanced  cases. 

Determination  of  the  Capacity  and  the  Form  of  the  Renal  Pelvis. — The 
capacity  test  requires  the  use  of  the  largest  caliber  of  catheter  which  will 
pass  the  obstruction  and  the  injection  of  a  carefully  measured  sterilized 
warm  solution  of  dye  within  the  view  of  cystoscopic  field  in  order  to 
determine  leakage.  Indigo-carmine  or  methylene  blue  is  usually 
employed,  the  latter  having  the  advantage  of  less  likelihood  of  decolori- 
zation  by  the  urme. 

A  graduated  syringe  of  at  least  250  c.c.  may  be  employed,  inasmuch 
as  anything  above  150  c.c.  capacity  of  the  sac  indicates  advanced  dis- 
ease, destruction  of  the  kidney  and  nephrectomy.  The  graduations  of 
the  syringe  must  be  such  as  to  permit  measurements  of  cubic  centi- 
meter differences  with  reasonable  accuracy.  Another  method  is  to  use 
a  smaller  syringe  with  smaller  graduations  and  a  two-way  cock,  whose 
suction  inlet  drains  a  beaker  containing  the  measured  quantity  of  dye 
into  the  syringe  and  whose  outlet  delivers  into  the  ureteral  catheter. 


900     IXFLAMMATJOXS  OF  RKXAL  PELVIS  AM)  I'AREXCHYMA 

Tlie  afiVcted  kidney  is  catheterized,  its  sac  evacuated  and  irrigated 
until  clean.  Then  the  dye  is  very  gently  flowed  into  the  sac  until  the 
patient  feels  slight  pain,  such  as  he  describes  as  suggesting  the  onset  of 
an  attack.  During  the  process  the  ureter  is  ke])t  within  the  cystoscopic 
field  ill  order  to  check  up  the  matter  of  leakage.  The  size  of  ureteral 
catheter  cannot  ordinarily  be  the  limit  of  the  ureter  but  rather  that  of 
the  obstruction. 

Determination  of  deformity  and  displacement  requires  the  use  of  the 
.r-ray  and  the  distention  of  the  sac  with  fluid  im])ervious  to  the  .r-ray. 
Braasch  has  done  much  work  in  this  held.  CoUargol  solution,  10  per 
cent.,  colloidal  siKcr  oxide,  oO  per  cent.,  have  been  ])referred  by  him, 
while  keyes  and  others  have  used  oO  per  cent,  argyrol  solution. 

In  this  work  it  is  well  to  take  an  .r-ray  photograph  before  and  during 
the  test  for  comparison;  and  likewise  to  combine  both  the  determi- 
nation of  the  capacity  and  the  deformity  at  the  one  sitting. 

The  position  of  the  patient  during  these  tests  is  important  as 
smaller  degrees  of  displacement  and  deformity  of  ureter  and  pelvis 
with  special  reference  to  the  site  of  the  obstruction  in  movable  forms 
disa])pear  in  the  lying-down  hospital  position  in  some  patients,  but 
reappear  in  the  standing  position,  hence  t\\ o  sets  of  .r-ray  photographs 
are  required.  O.  S.  Fo\\  ler^  in  a  long  series  of  cases  with  x-ray  studies 
has  shown  this  fact  very  well. 

Clinical  Significance  of  the  Capacity  of  the  Roial  Pelris. — Founded 
on  the  work  of  Braasch  and  others  is  as  follows: 

The  normal  kidney  pelvis  has  a  capacity  of  from  5  to  15  c.c;  a 
contractured  pelvis  or  one  in  the  midst  of  edema  as  m  acute  and  chronic 
suppurative  pyelitis  or  lithiasls  3  c.c;  a  dilated  pelvis  with  destruction 
of  the  kidney  substance  and  usually  indicating  nephrectomy  150  c.c. 
and  above.  Between  the  limits  of  contracture  and  dilatatioji  of  the 
pelvis  two  classes  may  be  placed,  namely — a  capacity  of  from  20  to  40 
CO.,  approximately  double  the  normal,  occurs  mostly  in  women  through 
hysteria  or  other  forms  of  anesthesia  with  failure  to  percei\'e  the  dila- 
tation as  under  the  pressure  of  pregnancy;  a  capacity  of  from  50  to 
150  c.c.  indicates  hydronephrosis  usually  of  non-operative  type  but 
requiring  medication,  irrigation  and  other  treatment.  The  larger  the 
capacity  of  the  sac  in  these  cases  the  nearer  the  borderline  of  nephrec- 
tomy do  they  approach. 

Diagnosis. — The  cardinal  subjective  symptoms  of  hydronephrosis  are 
renal  pain  and  tenderness  or  a  sense  of  weight  and  tumefaction  with 
little  change  in  the  act  of  urination. 

The  cardinal  objective  symptoms  are  during  an  attack  a  more  or  less 
tense,  cystic  tumor  in  the  kidney  region  with  a  little  tenderness,  and 
between  the  attacks  a  vague  thickening  in  the  intermittent  cases,  a 
movable  kidney,  or  in  the  remittent  cases,  somewhat  more  definite 
change. 

The  cardinal  cystoscopic  findings  are  both  ureteral  mouths  normal  or 

>  Tr.  Am.  Urol.  Assn.,  1912,  vi,  186. 


HYDRONEPHROSIS  901 

one  deformed  and  displaced  and  narrowed;  efflux  f>f  urine  absent  on 
the  affected  side  during  the  attack  or  flowing  feebly  and  not  in  rhyth- 
mical spurts,  or  between  the  attacks  the  same  drib})lijig  of  slightly 
turbid  urine  from  the  affected  side  may  continue.  Ureteral  catheterism 
relieves  the  distention  of  the  diseased  pelvis  in  steady  dripping,  the 
quantity  being  according  to  th  *  size  of  the  sac;  as  the  evacuation  is 
being  completed,  the  cardinal  subjective  symptoms  decrease  or  dis- 
appear. Cardinal  urinalysis  shows  some  pus  and  signs  of  renal  insuf- 
ficiency to  all  the  functional  tests  very  marked  on  the  affected  side,  less 
so  on  the  normal  side,  during  an  attack,  with  decrease  of  the  signs  in  the 
intervals. 

Differential  Diagnosis. — This  rests  on  the  cardinal  points  of  cystos- 
copy, ureteral  catheterism  and  radiographic  determination  of  pelvic 
capacity  and  deformity.  The  conditions  to  be  distinguished  from 
hydronephrosis  are  both  renal  and  extrarenal. 

The  renal  conditions  are  chiefly  lithiasis,  tumor,  pyonephrosis  and 
pyelitis,  and  the  extrarenal  diseases  are  located  in  the  gall-bladder, 
appendix,  pancreas  and  ovaries. 

Renal  lithiasis  is  distinguished  from  hydronephrosis  by  history  of 
gravel  and  colic,  severer  pain  referred  to  the  ureter,  scrotum  or  labium 
majus,  retraction  of  the  scrotum,  reflex  polyuria,  oliguria  or  anuria, 
blood,  pus,  detritus  and  crystals  in  the  urine.  In  practically  9  cases  in 
10  radiography  will  give  a  final  diagnosis  and  a  good  picture.  Cystos- 
copy reveals  a  characteristic  meatus  if  the  stone  is  below  the  brim  of 
the  bony  pelvis  within  the  lower  third  of  the  ureter.  Ureteral  cathe- 
terism encounters  the  characteristic  obstruction  of  stone. 

Hydronephrosis  may  be  due  to  impacted  slightly  movable  calculus 
and  would  therefore  give  the  s>Tnptoms  and  signs  of  both  conditions. 

Tumor  of  the  kidney  is  distinguished  from  hydronephrosis  by  the 
history  of  no  great  pain  or  other  sensation  in  the  kidney  region  unless 
a  sense  of  weight  later  on.  Copious  and  fierce  hematuria  is  regularly 
a  symptom,  usually  without  colic  except  through  clots.  Radiography 
shows  enlarged  kidneys,  deformed  pelvis  lawlessly  contracted  or 
dilated.  Pyonephrosis  is  distmguished  from  hydronephrosis  by  the 
presence  of  large  quantities  of  pus  in  the  urine  with  the  signs  of  obvious 
suppurative  inflammation  of  the  kidney.  Fever  is  a  more  prominent 
symptom  during  exacerbations. 

Pyelitis  is  distinguished  from  hydronephrosis  by  the  signs  of  acute 
or  chronic  inflammation  with  absence  of  contracture  or  deformity  of 
the  pelvis. 

Cholecystitis  and  cholelithiasis  are  distinguished  from  hydronephrosis 
by  the  following  points:  The  gall-bladder  is  opposite  the  ninth  rib 
in  front,  its  pain  is  central  and  with  migrating  stones  travels  down- 
ward and  inward,  and  is  referred  to  the  right  scapular  region.  Its 
attacks  are  intense  with  chills  and  fever.  Subjective  gastric  sjTaptoms 
precede  it  for  a  long  time  and  are  present  between  the  attacks.  In 
hydronephrosis  the  gastric  s\Tnptoms  are  more  common  during  the 
attack,  which  is  accompanied  by  urinary  conditions.     The  mass  in 


902     IXFLAMMATIOXS  OF  EEXAL  PELVIS  AXD  PAREXCHYMA 

cholelithiasis  is  more  nearly  central  and  anterior  while  that  hi  hydro- 
nephrosis is  lumbar,  lower  tlown  and  i)osterior.  (lall-stones  occur  in 
the  second  half  of  life,  hydronephrosis  in  the  first  half.  Jaiuidice  is  not 
an  micomnn>n  accompaniment  of  fjall-stone,  never  of  hydronephrosis. 
Between  the  attacks  in  cholelithiasis  i)ain  may  be  absent  but  a  degree 
of  discomfort  is  always  ])resent  in  hydronej^hrosis.  The  elements  of 
se])tic  absorption,  chill,  fever  and   prostration   are   ji;reater  in  gall- 


> 

Us 

k- 

^t 

V 

^S^ 

^^^    I       iKklj^'    N 

H^B^ 

Fig.  313  Fig.  314 

Fig.  313. — Internal  aspect  of  author's  case  of  hypernephroma,  showing  extensive 
lobulation  of  the  growth,  total  destruction  of  the  normal  kidney  arrangement,  almost 
complete  compression  of  the  pelvis  (P)  and  central  necrosis  of  the  growth  (A'^).  The 
ureter  (Ur)   is  much  thickened. 

Fig.  314. — This  is  the  same  specimen  as  Fig.  313,  but  presents  the*  outer  surface 
and  shows  the  prominence  of  the  lobules  of  the  growth.  The  absence  of  adhesions  is  at 
once  apparent.  P  is  pehas  and  Ur  ureter,  which  points  upward  because  the  specimen 
had  to  be  suspended  for  the  photograph  by  pins  in  the  thinnest  part. 


bladder  disease  than  in  hydronephrosis.  Ureteral  catheterism  and 
radiogra])h\'  ^^'ill  settle  the  diagnosis  even  when  the  diseased  and  dis- 
tended gall-l)ladder  overlies  the  kidney  region. 

Pancreatic  cysts  are  not  commonly  confused  with  hydronephrosis. 
Careful  subjective,  objective,  cystoscopic  and  radiographic  analysis 
of  the  case  is  required. 

Ovarian  cysts  arc  distinguished  from  hydronephrosis  by  the  gyneco- 
logical picture  and  physical  examhiation. 


NEOPLASM  OF  THE  KIDNEY  903 

Appendicitis  is  distinguished  from  hydronephrosis  by  the  acute 
onset  of  pain,  focussed  at  McBurney's  point,  and  marked  rigidity  of  the 
muscles  on  that  side  of  the  body.  Hydronephrosis  ji;ives  much  less 
severe  distress,  situated  in  the  hypochondrium  and  lumbar  r(;gions 
behind.  Cystoscopy,  ureteral  catheterism,  urinalysis  and  radiography 
will  clear  up  any  question  of  doubt  even  when  a  displaced  and  movable 
kidney  may  overlie  the  appendix. 

In  all  the  foregoing  extrarenal  conditions,  the  character  of  the  urine 
should  always  attract  attention  to  the  kidneys. 

Indications  of  Treatment.^ — They  are  applied  operative  and  nonoper- 
ative-  methods.  Surgical  interventions  are  as  follow:  A  sac  con- 
taining about  ten  times  the  normal  capacity  of  15  c.c.  is  accompanied 
by  so  much  atrophy  and  destruction  of  the  kidney  substance  with  loss 
of  function  that  removal  of  the  kidney  is  required.  Infection  of  the 
sac  carrying  the  disease  over  into  pyonephrosis  and  accompanied  by 
the  same  condition  of  the  kidney  requires  nephrectomy.  Pyelorrhaphy 
or  plastic-  suture  of  the  pelvis  and  ureter  is  indicated  when  the  sac  is 
small  and  the  function  good  for  the  restoration  of  any  deformity  of  the 
pelvis  and  the  relief  of  stricture.  A  catheter  in  the  ureter  is  a  service- 
able guide  in  this  work.  Suture  of  a  movable  kidney  into  its  normal 
bed,  ligature  and  division  of  a  bloodvessel  pressing  the  ureter,  and  th6 
jiemoval  of  a  stone  blocking  it,  are  all  indications  for  appropriate  cases. 

Nonoperative  measures  are  carried  on  as  follows :  During  the  attack 
its  distention,  pain  and  prostration  may  be  relieved  by  ureteral  cathe- 
terism, drainage,  lavage  with  cleansing  antiseptic  and  stimulating 
solution  of  mild  strength.  The  drainage  of  the  urine  and  the  detritus 
in  the  sac  must  be  thorough  and  then  the  medication  follows.  The 
retention  of  the  catheter  during  a  brief  period  may  therefore  be  de- 
manded not  over  a  few_ hours.  The  cleansing  solution  must  loosen  and 
dissolve  the  mucus  and  pus.  The  antiseptic  and  stimulating  solution  of 
choice  is  silver  nitrate  1  to  10,000  to  1  to  5000  cautiously  increased  to 
1  to  500  as  the  case  becomes  more  and  more  tolerant  through  the 
treatment. 

Nephrorrhaphy  and  drainage,  consisting  in  replacing  and  suturing  the 
kidney  in  such  a  position  that  deformity  of  the  pelvis  will  drain  well 
and  collect  residual  urine,  have  been  suggested,  tried  and  promise  well 
in  many  mild  cases. 

NEOPLASM  OF  THE  KIDNEY. 

Definition. — Neoplasm  of  the  kidney  is  a  tiunor  or  a  new  growth  com- 
posed of  tissue  elements  having  positive  histological  variations  from 
those  of  the  organ  itself. 

Varieties. — ^The  varieties  of  neoplasm  of  the  kidney  are  as  follows : 

Primary  renal  tumors  are  of  essentially  renal  origin  and  almost  inva- 
riably unilateral.  Secondary  new  growths  of  tha kidney  are  metastases 
commonly  of  a  general  carcinosis  or  of  a  cancer  situated  elsewhere. 

In  origin  neoplasms  of  the  kidney  are  parenchjTnatous,  arising  in  the 


904     I\FLAM}[ATinXS  OF  REX  AT.   PELVIS  AXD   I\\REXCin'}rA 

kidney  substance  itself,  or  adrenal,  stai'tiiii^-  in  the  cnilirvdnal  rest-cells 
of  the  sii])ra renal  gland. 

I  ncomplieated  renal  tumor  consists  of  the  new  growth  alone,  com- 
bined with  its  eiVects  on  the  kidney,  the  functioii  thereof,  and  the  system 
at  large.  Complicated  renal  new  growths  have  added  to  these  the 
local  ert'ects  of  suppurative  inflammation  in  pyelitis,  of  deformity  in 
hydrone]ihrosis  or  ])yone]ihrosis,  and  of  foreign  bodices  in  lithiasis. 


Fig.  315. — Adenosarcoma  of  the  left 
kidney.  Front  view  of  tumor  mass,  before 
operation.     (Author's  case.') 


Fig.  316. — Adenosarcoma  of  the  left 
kidney.  Front  view  immediately  after 
operation.  This  is  the  same  patient 
as  shown  in  Fig.  315.     (Author's  case.) 


Benign  neoplasms  of  the  kidney  are  almost  unknown ;  even  papilloma 
of  the  pelvis  has  strong  tendencies  toward  recurrence  and  malignant 
degeneration.  ^Malignant  new  growth  of  the  kidney  is  the  rule,  and 
usually  of  intense  type.  Hypernephroma  is  the  usual  form,  primary  in 
origin,  highly  malignant,  and  widely  disseminating  in  its  metastases. 
Sarcoma  is  primary  in  origin  l)ut  occurs  almost  solely  in  the  first  decade 
of  age.  Carcinoma  is  usually  secondary  and  rather  rare,  or,  still  more 
infrequently,  primary  in  advanced  age. 

Subjective  Syndrome. — Neoplasm  of  the  kidney  has  systemic  and 
local  signs. 

Subjective  systemic  s>Tn]>t()ms  may  be  the  earliest  and  chief  com- 
plaints  or   relatively   late    in    ajjpearance.     They   comprise   anemia, 


1  Med.  Rec,  August  26,  1911. 


NEOPLASM  OF  THE  KIDNEY 


905 


cachexia,  emaciation  and  weakness,  more 
severe  in  type  in  older  and  more  advanced 
cases.  Absence  of  these  symptoms  does  not 
argue  against  the  existence  of  the  tumor. 

Subjective  local  symptoms  may  a])pearin  any 
order  and  relation,  but  the  commonestarehema- 
turia,discomfort,tumorandurinarydisturbancc. 

Hematuria  is  due  to  varicosities  as  the 
vessels  are  pressed  and  obstructed,  or  to 
ulceration  as  necrosis  appears,  even  of  super- 
ficial type.  The  bleeding  is  copious,  rapid, 
without  clots,  as  a  rule,  sudden  and  unex- 
plained in  onset.  There  may  be  little  or  no 
blood  even  under  the  microscope  between 
fierce  attacks  of  hemorrhage.  Pain  during 
the  bleeding  is  rare  and  seems  to  be  caused 
by  clots.  Immediately  after  a  severe  hemor- 
rhage, the  functional  activity  of  the  kidney 
has  been  shown  to  be  decreased  temporarily 
more  than  a  previous  examination  might 
have  indicated. 

Discomfort  and  pain  are  commonly  of  the 
dull,  dragging  ache  or  sense  of  weight  type 
in  the  kidney  zone.  It  seems  to  be  due  to 
congestion  or  the  actual  mass  or  to  ulceration 
in  severer  degrees  of  pain.  The  typical  lanci- 
nating pain  of  cancer  often  referred  to  the 
ureter,  bladder  and  thigh,  is  not  uncommon. 
All  types  of  pain  are  constant  and  slow  in  their 
increase  without  colic  unless  there  are  clots 
passing  down  the  ureter. 


Fig.  317. — Adenosarcoma 
of  left  kidney.  Six  months 
after  operation  and  a  very 
few  days  before  death  of 
thoracic  and  abdominal  sec- 
ondary deposits.  This  is  the 
same  patient  as  shown  in 
Figs.  315  and  316.  (Au- 
thor's case.i) 


Fig.  318. — Adenosarcoma  of  the  left  kidney.  Front  \iew  of  tumor,  di\-ided  along  dts 
left  border  as  well  as  possible  toward  the  liilum.  Total  destruction  of  kidnej-  substance 
is  shown,  together  with  ca^dties,  thin  walls  in  places,  and  degenerated  tissue  and  blood 
clots  both  within  the  tumor  and  Ijdng  about  on  the  table.  This  is  from  the  same  patient 
as  shown  in  Figs.  315,  316  and  317.     (Author's  case.) 


1  Med.  Red.,  May  4,  1912. 


906     INFLAMMATIOXS  OF  RENAL  PELVIS  AXD  PARENCHYMA 

Tumefaction  of  the  neoplasm  is  a  subjective  sjiuptom  rarely  noticed 
until  quite  late  in  the  disease. 

Subjective  uruiary  s\Tnptoms  are  vesical  irritability,  frequency  of 
urination  and  pahi,  and  are  uncommon  in  the  micomplicated  cases. 
When,  however,  the  comjilications  of  pyelitis,  hydronephrosis,  pyo- 
nephrosis, lithiasis,  and  tlie  like,  have  supervened,  there  appear  all 
tlie  urinary  distin-bances  of  these  conditions  reflected  by  the  bladder 
exactly  as  though  the  neoplasm  itself  were  absent.  Hemorrhage  by 
its  fiuantity,  ra])idit.y  and  clots  may  at  any  time  disturb  the  bladder. 

Objective  Syndrome. — Neoplasm  of  the  kidney  requires  physical 
examination,  cystoscopy  with  its  adjuvants,  and  laboratory  findings, 
for  the  objective  analysis  of  the  case. 

Physical  exammation  of  the  system  at  large  reveals  suggestive  or 
obN-ious  state  of  absorption,  anemia,  cachexia,  emaciation  and  fever, 
all  according  to  the  development  of  the  case.  The  blood  count  will 
often  be  that  found  in  neoplasms  elsewhere  in  the  body. 

Physical  examination  of  the  renal  region  is  often  negative  in  eaily 
cases,  or  may  merely  suggest  tumor  or  resistance.  Older  cases  reveal  a 
distinct  enlargement.  INIetastases  may  be  anywhere  and  may  advisedly 
be  looked  for  in  the  lungs  and  bones  of  the  leg,  as  examples. 

Cystoscopy  with  its  adjuvants  should  include  inspection  of  the 
bladder,  meatoscopy,  ureteral  catheterization,  functional  tests  and 
radiography. 

Cystoscopic  inspection  of  the  bladder  is  almost  always  negative  in 
showing  the  viscus  as  a  whole  normal.  Secondary  deposits  in  the 
bladder  are  almost  unknown. 

Ureteral  meatoscopy  is  also  negative  in  early,  uncomplicated  cases. 
Later  when  circulatory  and  ureteral  pressure  may  have  super^^ened, 
slight  congestion  and  patulousness  of  the  mouth  and  prominence  of 
bloodvessels  may  be  suggestive  of  the  affected  side  but  not  pathogno- 
monic of  lesions.  Complicated  cases  possess  a  meatoscopy  of  all  the 
characteristics  of  the  complicating  conditions  spoken  of  and  described 
under  their  respective  sections,  namely,  pyelitis,  hydronephrosis,  pyo- 
nephrosis and  calculus. 

Ureteral  function  is  likewise  little  changed  in  uncomplicated  cases. 
Hemorrhagic  forms  of  the  disease  reveal  blood  during  the  attack  and 
sometimes  persistent  in  microscopic  quanlities,  usually  due  to  ulcerat- 
ing processes.  Between  the  excretion  of  urme  from  the  ureter,  blood 
may  be  seen  oozing  more  or  less  constantly  and  without  any  muscular 
activity  of  the  canal.  Complicated  cases  of  renal  neoplasm  have  the 
efflux  characteristic  of  the  complicating  lesions  duly  described  under 
their  respectiv^e  headings. 

Ureteral  catheterization  in  neoplasm  of  the  kidney  is  usually  easy, 
especially  the  uncomplicated  types,  but  may  be  difficult  in  the  compli- 
cated forms  according  to  the  condition  present  as  part  of  the  compli- 
cating disease  and  for  reasons  described  under  these  special  headings. 
Large  amounts  of  blood  through  or  around  the  ureteral  catheter 
followed  by  decreased  functional  activity  and  associated  with  other 


NEOPLASM  OF  THE  KIDNEY  907 

signs  is  strongly  suggestive  of  neoplasm  on  that  side.  Pdood  alone  in 
very  small  quantities  during  the  ureteral  catheterization  may  he  trau- 
matic and  shown  by  the  normal  kidney,  whose  function  will  vary  with 
such  factors  as  congestion  during  increased  work,  displacement  of  the 
kidney  and  traumatism  by  the  catheter. 

Functional  renal  tests  are  all  affected,  especially  in  the  advanced 
cases,  namely,  polyuria,  phloridzin,  indigo-carmin  and  phenolsulpho- 
nephthalein  tests.  The  degree  of  lost  function  is  that  of  destruction 
of  the  kidney  and  is  therefore  in  the  early,  uncomplicated  cases  com- 
paratively little  but  steadily  progresses  with  the  invasion  of  the  new 
growth.  When  the  complicating  conditions  arise  they  bring  with  them 
the  functional  conditions  found  in  pyelitis,  hydronephrosis,  pyoneph- 
rosis and  nephrolithiasis. 

Radiography.  —  Radiography  in  neoplasm  of  the  kidney  reveals 
deformity  and  displacement  of  the  kidney  outline  and  dilatation,  con- 
tracture and  deformity  of  the  pelvis. 

The  kidney  shadow  itself  is  rarely  a  large  factor  but  should  always  be 
studied. 

Pyelometry  or  measurement  of  the  pelvis  of  the  kidney  by  filling  it 
with  collargol,  colloidal  silver  or  argyrol,  followed  by  pyelography  or 
.T-ray  photography  of  the  pelvis  so  filled  should  be  carried  out  in  the 
lying  down  and  standing  positions  of  the  patient  exactly  as  m  displace- 
ment of  the  kidney.  This  test  will  go  farther  toward  studying  the 
relations  of  the  kidney  shadow  than  will  the  latter  alone. 

Urinalysis. — Urmalysis,  especially  of  the  separated  specimens,  fre- 
quently shows  hemorrhage  in  large  or  small  amounts  in  the  uncompli- 
cated cases,  combined  with  some  of  the  elements  of  nephritis.  Com- 
plicated lesions  show  all  the  analytical  findings  previously  described 
under,  these  diseases. 

The  normal  kidney  is  at  first  not  much  affected,  because  at  this 
period  even  the  diseased  kidney  is  doing  almost  full  duty.  ^Mien, 
however,  the  affected  kidney  has  been  greatly  destroyed  and  the  period 
of  overwork  and  congestion  is  at  hand,  tiunefaction,  tenderness,  func- 
tional variation,  analytic  elements  and  even  subjective  symptoms  may 
be  present. 

Secondary  deposits  in  a  kidney  originally  assumed  to  be  normal  may 
occur  and  have  been  described. 

Diagnosis. — The  diagnosis  includes  the  facts  of  presence  of  the 
tumor,  of  its  malignancy  or  benignancy,  of  its  displacement  and 
deformity  of  the  organ,  of  its  effect  on  the  function  of  the  diseased  and 
the  normal  kidney,  and  through  the  latter  fact,  decision  as  to  operability. 

The  earliest  possible  diagnosis  is  most  important  because  all  kidney 
neoplasms  are  highly  malignant. 

Subjective  symptoms  are  very  uncertain  in  the  early  period  and 
appear  only  when  general  health  has  been  affected,  excepting  only 
hematuria  which,  with  the  characters  described,  is  cardinal. 

Objective  symptoms  of  cardinal  value  are  hematuria,  reduced  renal 
function  and  the  suggestion  or  proof  of  tumor. 


90S     IXFLAMMATIOXS  OF  REXAL  PELVIS  AXD  PAREXCHYMA 

The  fliiof  jioints  in  the  diaii'Jiosis  aiv  the  measure  of  the  function  of 
tJie  oi)posite  kiihiey  and  the  oi)erahility  of  the  disc^ased  organ,  whieh 
may  usually  he  co\ered  1)\-  reiiaidiiiu'  the  relation  of  all  the  facts  in  the 
case. 

Differential  Diagnosis  distinuuishes  neoi)lasni  from  mol)ility  and  dis- 
])laeement  of  the  kidney.  hydr()nephrosis,  inllammatory  conditions, 
esjx'cially  supi)iu'ation  and  tuberculosis,  idiopathic  lienuituria  and 
renal  calculus. 

Mohilifi/  and  displaceDwnt  of  the  kidnci/  differ  from  iieophifiin  in  the 
earlier  and  rather  more  constant  symi)toms  in  the  usually  almost  normal 
function  and  lu'ine,  in  the  readily  ])alpai)le  displaced  organ,  and  hi  the 
definite  ])yelograi)hic  revelations  in  the  standing  and  reclining  j)o,sitions. 

Ilifdronephrofii^s'  differs  from  neoplasm  of  the  kidneii  in  having  a  mass 
regularly  and  earlier  within  reach,  in  its  connnon  interndttent  colic, 
in  its  muisual  hematuria,  and  in  its  ])ersistent  and  increasing  ])yuria, 
in  its  cystoscopic  findings  \\\t\\  cystoscope,  ureteral  catheterization  and 
other  adjuA'ants.  Pyelometry  and  ])yelography  are  again  typical  and 
really  final  in  the  diagnosis.  Hydronephrosis,  which  is  an  early  sequel 
of  neoplasm,  is  distijiguishable  only  at  the  time  of  ()])eration. 

Snppuratife  infla)nm(ition  of  the  kiditei/  differs  from  neoplasm  in  its 
typical  systemic  condition,  usually  higher  degree  of  nepliritis  and 
tendency  of  the  bladder  to  secondary  infection.  Cystoscopy  with  all 
its  adjuvants  settles  the  proof,  as  shown  in  pre^■ious  pages.  Comj^li- 
cated  cases  of  neoplasm  with  the  early  onset  of  ])yelitis,  pyelonephritis 
and  pyonephrosis  are  established  only  at  the  time  of  operation,  hence  it 
is  impossible  to  give  any  system  of  clinical  distinction. 

Tuhercniosis  of  the  I'idveii  differs  from  neoplusni  in  the  presence  of 
Bacillus  tuberculosis,  established  by  bacteriology  and  animal  experi- 
mentation, and  in  the  mvariable  presence  of  polyuria,  pollakiuria, 
dysuria,  typical  meatoscopy,  tuberculous  bladder,  and  sooner  or  later 
tuberculous  temperature,  absorption  and  emaciation.  Hematuria  in 
tuberculosis  is  almost  always  present  in  slowly  progressing  micro- 
scopic quantities  and  only  very  rarely  in  the  copious  attacks  of 
neoplasm. 

Idiopathic  hematuria  differs  from  neoplasm  in  having  no  cachexia, 
only  anemia  which  may  be  severe.  The  bleeding  is  of  long  duration  in 
its  history,  far  beyond  the  possibility  of  any  neoplasm,  namely,  often 
many  years.  The  bleeding  is  directly  related  with  defijiite  change  in 
the  physical  economy,  such  as  exercise,  rising  from  bed,  overeating, 
jars  anfl  vibration  as  in  falls  and  railroad  or  automobile  travel.  Renal 
functioji  is  decreased  only  after  the  bleedijig  and  then  temporarily. 
There  are  no  signs  of  nej^hritis  or  other  change  iji  the  kidney,  and  the 
normal  kidney  shows  no  congestion  or  hypertrophy. 

Nephrolithiasis  differs  from  neoplasm  of  the  kidney  in  the  constancy 
of  severe  colic  with  vesical  disturbance  and  urmary  changes,  in  the 
absence  of  enlargement  of  the  affected  kidney,  in  the  findings  with 
wax-tipped  catheters,  filiform  guides  and  meatoscopy,  in  its  radio- 
graphy positi\e  for  stone  in  nearly  90  per  cent,  of  all  cases,  in  its 
detritus  in  the  urine  and  its  pjoiria  and  hematuria,  the  former  pre- 


UTHIA^IH  OF  THE  KIDNEY 


909 


dominating  largely  ov.er  the  latter.    Caleiihis  profhicefl  by  a  neoplasm 
in  its  early  history  is  recognizable  only  at  the  time  of  ojjeration. 

Treatment.  —  Neoplasm  of  the 
kidney  has  the  indications  of  first, 
knowledge  of  the  function  of  the 
opposite  kidney,  because  it  must 
perform  the  duty  of  two  organs 
after  removal  of  the  disease,  and 
because  metastases  may  be  within 
it,  and  second,  operability  of  the 
disease  itself.  If  the  normal  kid- 
ney is  below  the  work  of  the  body 
no  surgical  intervention  is  possible 
but  only  medicinal  support  of  the 
patient  available.  Nephrectomy 
may  remove  the  disease  success- 
fully but  thus  far  from  40  to  50 
per  cent,  of  all  cases  die  far  within 
two  years  and  very  few  outlive 
this  period. 


LITHIASIS  OF  THE  KIDNEY. 


Fig.'  319. — Lithiasis  of  the  kidney, 
showing  a  shadow  in  the  pelvis  exactly 
where  a  ureteral  calculus  near  the  outlet 
would  be  expected  to  show.  (Author's 
case.) 


Definition  and  Varieties. — Lithia 
sis,  of  the  kidney.    Nephrolithiasis 

or  renal  calculus  may  be  regarded  as  a  calcareous  or  stone-like  concre- 
tion found  in  the  kidney  or  its  pelvis.  The  varieties  of  nephrolithia- 
sis are  primary  and  secondary. 
The  primary  cases  involve  the 
formation  of  the  calculus  idio- 
pathically,  that  is,  without  ap- 
parent antecedent  renal  infec- 
tion or  disease.  The  secondary 
cases  imply  the  appearance  of 
the  stone  through  decompo- 
sition of  the  urme  after  other 
renal  diseases,  especially  in- 
fection, suppuration  and  ob- 
struction as  the  underlying 
conditions. 

Renal  calculi  may  also  be  soli- 
tar}-,  or  multiple  through  forma- 
tion or  fragmentation.  They 
may  arise  in  the  body  of  the 
pelvis  or  in  the  infundibula.  In 
form  they  may  be  spheroid, 
ovoid  or  irregularly  branched 
and  in  size  so  small  as  to  pass 
through  the  ureter  to  the  outer 


Fig.  320.— Lithiasis  of  the  kidney.  The 
shadow  is  as  of  a  stone  in  the  left  ureter 
shown  to  be  outside  it  by  the  passage  of 
the  bismuth  opaque  catheter  upward  to  the 
kidney.  The  zebra  lead  catheter  is  in  the 
right  ureter.  Both  ureters  are  normal  in  their 
course.  Plate  taken  October  5,  1914.  This 
is  the  same  case  as  shown  in  Figs.  319  to 
326,  both  inclusive.    (Author's  case.) 


910     IXFLAMMATIOXS  OF  REXAL  PELVIS  AND  PARENCYIIMA 

world  with  rolativoly  mild  syin])t(>iiis  as  <;;ravol  or  sufficieiitlx-  larij;o  to 
cause  intense  syni]itonis  in  this  transit,  or  so  large  as  to  hll  tiie  pelvis  as  a 


Fig.  321 


Fig.  322 


Fig.  321. —  Litliiasis  of  the  kidney.  This  is  the  same  case  as  in  Fig.  319.  Shadow 
is  of  stone  in  the  left  ureter  shown  to  be  outside  it  by  the  passage  of  the  opaque 
catheter  upward  to  the  kidney.  One  bismuth  catheter  is  in  the  right  ureter.  The  phxte 
was  taken  June  2.5,  1915,  and  the  mass,  probably  a  lymphatic  gland,  has  enlarged.  At 
the  operation  the  ureter  was  exposed  and  palpated  but  no  stone  corresponding  ^vith  the 
mass  found  in  it.    The  mass  might  be  condensation  of  bone  substance  in  the  sacrum. 

Fig.  322. — Author's  case  of  impacted  calculus  in  the  ureter  with  hydroureter.  The 
concretion  is  well  shown  with  its  concentric  layers  and  the  opaque  catheter  passing  in 
front  and  nearly  beside  it.  Coiled  in  the  rectum  is  a  lead-core,  flexible,  urctlu-al  bougie, 
size  27  Fr.,  whose  shot  filling  makes  the  surface  appear  sawtoothed. 


Fig.  323 


Fin.  ■.r2i 


Fig.  323. — Author's  case  of  impacted  calculus  in  the  ureter  with  hydroureter.  The 
calculus  is  distinctly  apparent  with  the  opaque  catheter  passing  in  front  and  nearly  to 
one  side  of  it.  The  shadow  of  the  rectum  fillcfl  with  bismuth  paste  is  shown  to  be  chiefly 
clear  of  the  stone  and  a  small  portion  in  front  of  it  showing  that  the  stone  was  not  an 
enterolith.    This  is  the  same  case  as  Figs.  319  to  326. 

Fig.  324. — Author's  case  of  impacted  calculus  in  the  ureter  with  hydroureter.  This 
is  the  same  case  as  Figs.  319  to  326.  The  calculus  is  di.stinctb'  apparent  with  the  opaque 
catheter  in  front  and  beside  it.  The  argent ide  has  filled  the  ureter  abo%'e  it  and  flowed 
over  its  face  to  the  lower  pole,  thus  proving  that  the  concretion  was  in  the  ureter. 


LITIIIASIS  OF  THE  KIDNEY 


911 


whole,  reaching  its  remote  h'mits  with  its  branches.    '^I'he  o})struction  of 
the  stone  at  the  mouth  or  in  the;  course  of  the  ureter  may  be  sudden  anri 


Fig.  325  Fig.  326 

.  Fig.  325. — Author's  case  of  impacted  calculus  in  the  ureter  with  hydroureter.  This 
is  the  same  case  as  shown  in  Figs.  319  to  326,  inclusive.  Dilatation  of  the  upper  ureter, 
the  isthmus  of  the  ureter  and  the  dilatation  of  the  pelvis  of  the  kidney  are  well  out- 
lined, including  the  calyces  which  are  individualized. 

Fig.  326. — Lithiasis  of  the  kidney.  Secondary  and  extreme  dilatation  of  the  ureter 
and  renal  pelvis,  due  to  the  obstruction  of  the  calculus,  are  shown.  This  is  the  same 
case  as  Fig.  319.     (Author's  case.) 


Fig.  327. — Author's  case  of  polylithiasis  of  the  kidney.  The  figure  is  the  inside  of 
the  kidney  open  from  end  to  end,  including  the  ureter,  showing  great  thickening  in  the 
pelvis  and  ureter,  destruction  of  the  parenchyma,  with  multiple  stones  in  the  multiple 
abscess  cavities. 


912     IXFLAMMATJOXS  OF  REXAL  PELVJS  AM)  l'Alx'K.\CHYMA 

absolute  or  chronic,  partial  and  intormittejit  in  its  entire  closure.    The 
stones  may  he  "  silent,"  resident  in  the  ]Hdvis  with  no  or  few  symptoms 

for  indefinite  ])eriods,  or  "ram- 
l)ant,"  giving  constant  s^-mptoms 
})imctuated  with  intense  attacks 
of  renal  colic,  or  fixed,  and  im- 
])acted,  resident  at  a  definite 
l)oint  of  the  pelvis  or  ui)])er 
ureter,  or  movable,  changing 
their  ])osition  from  time  to  time 
always  with  syni])toms,  or  migra- 
tory, ])asshig  in  steady  progress 
or  in  stages  from  the  pelvis  to 
the  bladder,  also  always  with 
sym]3tonis.  The  stones  may  show 
faceted,  rough  or  smooth  sur- 
faces. 

Etiology  and  Pathogenesis.  — It 
is  ])robable  that  all  stones  in  the 
kidney  originate  from  some  pre- 
vious disease,  although  symi)t()ms 
may  have  escaped  attention. 
Their  formation  is  essentially  a 


Fig.  328. — Radiop:raph  showiuK  large 
calculus  in  the  rinht  ureter  which  throujih 
its  oblique  position  cast  a  shadow  longer 
than  itself,  also  showing  two  small  calculi 
in  the  bladder  just  above  the  sj-niphysis 
pubis,  of  the  same  apparent  size  as  through 
the  cystoscope.  The  effect  of  thLs  stone  is 
shown  by  the  kidney  of  Fig.  329. 


precipitation  of  the  urinary  salts.     In  the  secondary  cases  this  occurs 
upon  a  nucleus  of  mucopus.    In  the  primary  cases  such  nucleus  is  not 


Fii;.  '.'/J'J. — Plight  ;uid  left  kiduejs  ojK'ued.  Front  view.  In  the  right  kidney,  the 
two  major  abscess  cavities  are  distinctly  seen,  the  larger  involving  much  of  the  lower  pole 
axially,  laterally,  and  anteroposteriorly,  and  the  smaller  abscess  cavity  situated  above 
it.  The  radiographic  shadows  corresponded  more  with  the  abscess  walls  than  witli  the 
contained  calculi.  The  pelvis  of  the  kidney  as  a  whole  show's  signs  of  chronic  inflamma- 
tion, the  mucous  membrane  being  rough  and  corrugated.  The  thickening  of  the  pelvic 
wall  is  distinctly  shown  in  the  cut  edge.  The  ureter  appears  to  be  patent.  The  left 
kidney  is  in  passable  condition  and  shows  the  usual  changes  in  chronic  diffuse  nephritis. 

so  obvious.    When  of  size  too  large  to  pass  through  the  ureter  their 
residence  in  the  })elvis  of  the  kichiey  traumatizes  the  mucosa  by  attri- 


LITJIIASfS  OF  TIJE  KIDNEY 


913 


tion,  infection  follows  or  is  'd\\\f- 
mented  along  with  further  decom- 
position of  the  urine.  Next  ensues 
a  degree  of  p,voiie))hrosis,  pyelo- 
nephritis and  increase  of  the 
chronic  interstitial  nephritis  which 
may  have  preceded  the  calculus. 
The  obstruction  by  the  stone  may 
be  at  any  point,  as  the  uretero- 
pelvic  juncture,  elsewhere  in  the 
upper  third  of  the  ureter,  at  the 
brim  of  the  bony  pelvis  or  in  the 
lower  third  near  the  bladder.  The 
secondary  disease  or  destruction 
of  the  kidney  is  in  the  early  cases 
recoverable  but  when  deformity 
of  the  kidney  and  pelvis  is  pres- 
ent, pyonephrosis,  decomposition 
of  the  residual  urine,  with  alkaline 
phatic  salts  adding  to  the  stone  ali 


Fig.  331. — Author's  case  of  extensive 
nephrolithiasis  (operation  refused).  The 
whole  kidney  is  practically  replaced  by 
stones,  of  which  eight  or  ten  discrete 
shadows  may  be  distinguished.  Pyuria 
for  four  years,  with  only  occasional  scanty 
hemorrhage  and  with  little  or  no  pain 
characterized  the  case.  Palpation  elicited 
crepitation  of  the  stones  and  the  kidney 
nearly  reached  the  crest  of  the  ilium. 
Wax-tipped  catheter  test  revealed  abun- 
dant scratches.  Excretion  of  urine  and 
dye  almost  abolished.  Opposite  or  left 
kidney  normal  to  functional  test  and  ex- 
cretion of  urine  with  variable  small 
amounts  of  pus. 

58 


Fig.  330. — Coral  stone  of  the  kidney. 
The  left  kidney  pelvis  is  filled  with  a 
stone  forming  a  mold  of  it,  with  possibly 
separate  stones  in  addition.  The  left 
ureter,  right  kidney,  pelvis  aud  ureter  are 
all  negative  for  stones.       (Author's  case.) 

infection  and  precipitation  of  phos- 
•eady  present  or  forming  new  calculi. 
Even  such  cases  may  give  rela- 
tively bearable  s;)miptoms  so  that 
cases  are  seen  in  which  the  pyo- 
nephrosis has  converted  pelvis 
and  kidney  into  one  rather  thin- 
walled  sac. 

Chemical  Composition  of  Calculi. 
— Is  the  same  as  that  found  in 
vesical  and  ureteral  calculi  and 
oxalates,  namely,  uric  acid  in 
most  primary  cases,  phosphates 
in  the  majority  of  secondary  cases. 
Compound  stones  are  found  in 
which  a  uric  acid  nucleus,  after 
infection,  of  the  pelvis  with  de- 
composition of  urme,  receives  a 
deposit  of  phosphates. 

Uric  acid  calculi  occur  m  acid 
urine,  often  associated  T\ith  uric 
acid  and  urate  crystals.  They  are 
commonly  brown  with  red  or  yellow 
tone. 

They  are  somewhat  apt  to 
be  small  and  faceted  because 
multiple,  hard  rather  than  soft, 
ovoid  or  spheroid,  rough  and  irri- 
tating. They  commonly  form  the 
centers  of  compomid  stone  with 
phosphates   and  other  secondary 


914     jyFLAMMATIOXS  OF  REXAL  PELVIS  AND  PARENCHYMA 

deposits  upon  them.  They  [ivv  the  most  common  stone  in  so-called 
primary  nephroHthiasis. 

O.valdir  of  li)ni'  stones  also  oeenr  in  acid  nrine,  are  hrowji  or  hlaekisli, 
darker  than  the  uric  acid  calculi,  very  rou^h,  hardly  ever  smooth,  consti- 
tuting the  so-called  mulberry  calculus.  The  urine  conunoidy  contains 
oxalate  crystals.    Oxalate  stones  ap])ear  in  secondary  cases,  as  a  rule. 

Ctf.sfin  sfoncs  are  Acrv  rare  and  occur  onl\'  in  acid  urine. 


Fig.  .332. — Author's  case  of  multiple  nephrolithiasis.  The  bottle  contains  a  large 
stone  impacted  in  and  removed  from  the  rijiht  ureter.  The  diagram  shows  29  stones 
removed  from  the  left  polycystic  kidney.  The  stones  are  shown  as  nearly  as  possible 
in  the  infected  cysts  or  abscesses  as  found.  When  compared  with  the  3*-ray  photograph 
of  this  case  in  Fig.  333,  the  arrangement  of  the  stones  is  substantially  correct  allowing 
for  the  fact  that  the  diagram  presents  the  specimens  "'on  the  flat"  while  the  photograph 
is  "on  three  dimensions."  (Referred  by  Dr.  Benjamin  T.  Tilton,  who  operated  with 
author's  assistance.) 

Phosphatic  Hones  are  the  rule  in  alkaline  lu'uie,  less  so  in  acid  urine, 
are  commojdy  white,  s])heroi(l,  larger  than  the  others  because  more 
rapiflly  formed,  rough  but  less  so  than  the  oxalates.  The  urine  is  very 
full  of  phos])hatic  detritus. 

Subjective  Syndrome. — The  subjective  syndrome  includes  systemic, 
reHex,  renal,  vesical  and  urinary  symptoms. 

The  subjective  systemic  symptoms  of  stone  iji  the  kidney  are  com- 
monly those  of  indefinite  disturbance  followed  by  the  symptoms  of 
suppuration  and  obstruction,  such  as  fever,  chilliness,  occasional  chills, 
malaise,  tendency  to  loss  of  weight  and  strength,  and  partial  or  com- 
plete anuria  from  time  to  time. 

The  subjective  reflex  symptoms  of  renal  calculus  occur  during  the 
attacks  of  colic  and  are  nausea,  vomiting  and,  at  times,  syncope. 

The  subjective  renal  symi)toms  of  nephrolithiasis  are  a  history  of 


LITHIASIS  OF  THE  KIDNEY 


915 


renal  colic  and  frequently  of  passing  {i;ravel  or  sand  durinj^  a  long  jjeriod 
of  years  followed  later  by  more  severe  attacks  with  possibly  the  passage 
of  larger  concretions.  The  pain  of  the  colic  is  in  the  kidney  regions  in 
the  costovertebral  angle  behind  or  along  the  free  border  of  the  ribs  in 
front.  It  is  the  dull  ache  of  pyonephrosis  punctuated  with  cramps  of 
severe  type,  sudden  in  onset,  due  to  disturbance  of  the  stone  in  its  bed. 
Renal  sensations  may  be  altogether  absent  except  during  the  colic 
itself.  Migration  or  attempts  at  migration  of  the  stone  cause  the  most 
severe  cutting,  tearing  pain  with  intermissions  as  the  stone  momen- 
tarily is  arrested,  then  with  fresh  paroxysms  as  its  progress  down  the 
ureter  is  resumed.  The  pain  is  freriuently  referred  to  the  bladder, 
labium  majus  in  the  female  and  scrotum  and  testicle  in  the  male,  or 
even  down  the  inner  surface  of  the  thighs  along  the  crural  branch 


Fig.  333. — Author's  case  of  numerous  stones  in  the  left  kidney  only,  as  shown  in  Fig. 
332.  The  ureter  is  without  stones  from  the  sacroiliac  synchondrosis,  while  the  right 
ureter  had  a  stone  well  below  the  pelvic  brim  and  10  c.c.  from  the  outlet. 

of  the  genitocrural  nerve.  Fainting,  muscular  spasm  of  the  abdomen 
and  the  attitude  of  spastic  flexion  of  the  lower  extremities  or  body  as  a 
whole  may  be  assimied.  Morphin  is  the  only  drug  in  free  dose  which 
will  control  this  pain. 

The  attack  varies  in  length  according  to  the  size  of  the  stone,  the 
trauma  caused,  the  distance  traveled  and  the  violence  of  effort  to  expel 
it,  from  a  brief  period  rarely  to  a  prolonged  lapse  of  several  hours  com- 
monly. The  attack  ceases  when  the  stone  passes  from  the  ureter  into 
the  bladder  or  comes  to  rest  higher  in  the  ureter  after  the  spasm  for  its 
expulsion  has  stopped.  The  stone  may  never  leave  the  pelvis  of  the 
kidney  or  after  migrating  a  few  centimeters  return  to  the  pelvis.    The 


910     I\FLAMMAriO\<^  OF  RP:\AI.  I'KIAI.'^  AM)  rARFXCIlYMA 

patient  is  left  nervously  and  physically  exJiansted  and  not  int'rec[uently 
severely  shocked,  with  small,  thready  pulse,  pallor,  cold  perspiration 
and  lowered  temperature.  Renal  and  ureteral  soreness  frecjuejitly 
remains  hchind  on  the  afVected  side  from  the  distnrl)an('(>  and  on  the 
normal  side  from  the  congestion. 

After  an  interval  of  rest  from  pain,  often  of  very  long  duration,  days, 
weeks  or  months,  sudden  jar  or  mu.scular  exercise  will  jirovoke  a  fresh 
attack.  Between  the  attacks  there  is  no  pain  iji  the  primary  ne])hro- 
litiiiasis  without  infection  and  no  obvious  change  in  the  general  health. 


Fig.  334. — Renal  calculi.    One  has  been  rotated  on  its  long  a.xis  by  the  ureteral  calculus. 

(Author's  case.) 

Primary  nephrolithiasis  with  acute  infection  is  marked  by  septic 
symptoms  and  signs,  iexer,  pus  and  blood  in  the  urine,  pain,  tenderness, 
and  tumefaction  over  the  afiected  kidney  with  severe  local  muscular 
spasm,  all  added  to  the  i)icture  of  the  renal  colic  before,  during  or  after 
its  onset. 

Secondary  nephrolithiasis  shows  the  s\niptoms  of  the  antecedent 
pyonephrosis,  jiN'elonephritis,  displaced  kidney,  and  the  like,  possibly 
masking  the  symptoms  of  the  stone  until  the  advent  of  the  attack  of' 
the  renal  colic.  Pyelonephritis  and  i)yonephrosis  themselves  secondary 
to  the  renal  calculus  after  infection,  give  all  the  symptoms  previously 
described  of  chronic  suppuration  of  the  kidney  and  its  pelvis,  which  in 
turn  may  predominate  over  the  symptoms  of  the  stone. 


LirillASIS  OF  THE  KIDNEY  917 

The  opposite  healthy  or  less  diseased  kidney  during  an  attack  of 
renal  colic  may  be  normal  and  without  definite  symptoms,  or,  on 
account  of  the  pain  and  hypertension,  may  become  greatly  congested 
and  give  subjective  and  objective  signs  accordingly,  during  the  attack 
and  not  infrequently  after  it,  in  the  latter  event  occasionally  more 
obviously  than  the  diseased  kidney.  These  findings  are  most  common 
when  the  anuria  of  obstruction  is  absolute  so  that  the  opposite  kidney 
must  suddenly  take  up  the  entire  work  of  the  body. 

Subjective  Vesical  Symptoms. — ^These  signs  are  not  very  manifest  and 
are  chiefly  pollakiuria  during  the  attack — a  reflex  manifestation  whose 
intensity  commonly  agrees  with  that  of  the  attack.  If  the  calculus 
reaches  the  bladder,  in  some  cases  irritability  and  tenesmus  ensue  at 
once. 

Subjective  Urinary  SymjAoms. — There  are  four  important  factors: 
hematuria,  pyuria,  sediment  and  gravel. 

Hematuria,  or  blood  in  the  urine,  may  occur  before,  during  or  after 
an  attack  of  renal  colic.  Large  quantities  of  blood  are  rather  rare  and 
when  present  are  usually  part  of  the  attack  itself.  Microscopic  quanti- 
ties of  blood  are  much  more  common  and  with  few  exceptions  are  a  real 
factor  during  the  attack  and  continue  for  some  time  after  the  attack, 
many  cases  never  being  without  blood  as  a  microscopic  element. 
Blood  preceding  the  attack  of  colic  is  least  frequently  seen.  The 
sources  of  the  bleeding  are  the  wounds  of  the  mucosa  made  by  the  stone. 
Bleeding  is  more  common  in  the  primary  and  the  uninfecting  cases,  as 
the  advent  of  suppuration  with  its  thick,  tenacious  discharge  seems  to 
reduce  the  bleeding. 

Pyuria,  or  pus  in  the  urine,  shows  only  in  macroscopic  quantities 
in  the  infected  and  secondary  cases,  and  is  absent  as  a  subjective  symp- 
tom in  the  primary  uninfected  cases.  Suppurative  nephrolithiasis 
gives  any  possible  variety  in  the  occurrence  and  condition  of  the  pus. 

Sediment  in  the  urine  chiefly  as  crystals  does  not  often  attract  the 
patient's  attention  unless  the  quantity  is  rather  large.  On  urinalysis, 
however,  this  condition  is  reversed. 

Gravel,  sand  or  small  calculi  individual  or  fragmented  are  not 
uncommonly  noted  by  the  patient.  In  the  early  history  of  the  case, 
before  the  true  symptoms  of  the  kidney  stone  are  apparent,  the  gravel 
and  the  sand  are  more  common,  while  in  the  later  history  of  the  case 
the  small  or  broken  calculi  occur.  Each  condition  is  respectively 
definitely  pathognomonic  of  the  metabolism  which  leads  to  the  stone 
formation  and  of  the  actual  presence  of  the  stone  itself. 

Objective  Syndrome. — Nephrolithiasis  demands  physical  examination, 
cystoscopy  with  its  adjuvants,  and  urinalysis. 

Physical  examination  is  in  the  interval  between  the  attacks  of  colic, 
usually  negative  except  for  renal  tenderness  and  muscular  rigidity  in 
the  primary,  uninfected  cases.  The  suppurative  conditions  to  which 
nephrolithiasis  is  secondary  give  the  signs  already  described  under 
pyelonephritis  and  pyonephrosis. 

During  an  attack  of  renal  colic,  the  patient  shows  all  the  objective 
signs  systemically  of  shock,  and  locally  of  renal  difficulty  of  severe  t^pe. 


918     /.V/-'L.l.U.U.l770.V.s'  OF  REXAL  P7?Ll7.s"  .IA7)  P^RF^'CIIY^fA 

Ci/stoscopi/  and  iL\'  adjiivauLs'  iiichulo  inspection  of  the  bladder, 
ureteral  meatoscopy,  ureteral  acti\'ity,  ureteral  catheterism,  functional 
tests  and  radiography. 

Cystoscopy  reveals  a  normal  bladder  in  the  primary,  uninfected 
cases,  whereas  the  secondary  cases  give  the  findings  ])reviously  s})oken 
of  under  pyelone|)hritis  and  j)\onephrosis.  They  cliiefly  comprise 
cystitis  localized  about  the  ati'ected  ureter. 

Ureteral  meatoscopy  between  the  attacks  of  renal  colic  shows  on  the 
aflected  side  in  ])rimary,  uninfectetl  cases,  no  definite  difference  unless  a 
slight  suggestion  i)ointing  to  the  diseased  kidney.  In  tlie  secondary, 
infected  cases,  however,  the  findings  are  those  of  the  antecedent  con- 
dition, especially  the  suppurations  and  tuberculosis.  The  higher  the 
disease  is  in  the  ureter  the  less  the  change  in  or  about  its  mouth  as  a 
rule,  and  vice  irrsa. 

During  an  attack  of  renal  colic  cystoscopy  is  practically  impossible. 
The  affected  mouth  is  probably  contracted  in  muscular  spasm  while 
the  normal  side  is  delivering  urine  in  strong,  rapid  spurts.  One  would 
suppose  that  blootl  would  issue  in  some  cases  during  the  attack  while 
pus  might  be  blocked  from  its  descent. 

After  an  attack  of  colic,  the  affected  ureteric  mouth  is  sometimes 
more  congested,  inflamed  and  edematous  than  before,  owing  to  the 
traumatism  above. 

I'reteral  activity  can  likewise  rarely  be  studied  except  in  the  intervals 
before  or  after  an  attack.  During  an  attack  of  renal  colic  Pilcher^  in 
one  of  his  own  cases  states :  "  The  diseased  side  showed  a  small  dribbling 
of  urine  while  the  normal  kidney  was  delivering  urine  to  the  bladder 
in  strong,  rapid  spurts  showing  the  reflex  stimulation."  The  character 
of  the  urine  from  the  affected  side  will  depend  on  Avhether  or  not  the 
case  is  a  primary,  uninfected  or  a  secondary,  infected  case,  and  whether 
or  not  hemorrhage  is  a  factor. 

Ureteral  catheterism,  easy  in  the  primary,  uninfected  cases,  but  in 
the  secondary,  su])purative  cases  may  present  all  the  difficulties  due  to 
the  deformity,  thickening  and  inelasticity  of  the  in-eters  sj)oken  of  in 
preceding  pages  under  suppurative  ureteritis.  The  obstruction  by  the 
stone  is  usually  not  marked,  differing  from  this  condition  in  ureteric 
stone.  Catheters  with  waxed  tips,  filiform  guides  with  waxed  tips 
(Harris'  method)  and  telephonic  catheters  (Cabot's  method)  all  have 
their  value  but  in  somewhat  less  degree  than  in  ureterolithiasis.  The 
reasons  appear  to  be  that  the  calculus  in  the  pelvis  of  the  kidney  is 
relatively  less  closely  opposed  to  the  catheter  tip  and  hence  scratches 
the  wax  less  constantly  than  in  ureteric  stone.  Pelvic  calculi  are  also 
more  m()\'able  and  jius-covered  than  ureteric  stones  and  hence  less 
accessible  to  the  wax-tipped  instruments. 

Functional  Tests. — The  functional  tests  depend  on  the  destruction  of 
the  kidney  present  and  therefore  are  related  with  the  antecedent,  inci- 
dent and  subsequent  conditions  of   the  kidney  and  calculus  in  their 

'Practical  Cystoscopy,  1911,  p.  336. 


LI  T  in  A  HI  H  OF  TIIK  KIDNEY  919 

mutual  relations.  Primary,  uninfected  cases  usually  show  the  least 
variation,  while  the  secondary,  suppurative  cases  may  show  any  and 
all  degrees  of  change  from  the  normal  at  any  given  examination  and 
between  successive  examinations.  Necessarily  the  results  of  all  the 
common  functional  tests  are  affected,  namely,  the  polyuria,  phloridzin, 
indigo-carmin,  and  phenolsulphonephthalein  tests.  While  the  affected 
kidney  thus  varies,  the  healthy  kidney  will  show  no  change  from  the 
normal  unless  it  is  itself  in  a  state  of  congestion. 

Experimental  Renal  Colic. — In  nephrolithiasis  renal  pain  may  be 
caused  by  the  fact  that  the  diseased  kidney  is  readily  excited  to  colic- 
like pain  by  overdistention  of  its  pelvis.  This  fact  points  to  the  side 
of  the  disease  but  does  not  distinguish  inflammatory,  suppurative  and 
calculous  conditions  from  each  other.  The  technic  is  the  same  as  for 
mensuration  of  the  capacity  of  the  kidney  pelves.  The  writer,  however, 
had  a  case  of  very  severe  reaction  in  a  patient  with  hydronephrosis 
notwithstanding  strict  asepsis  and  great  gentleness.  He  is  therefore 
of  the  opinion  that  such  a  test  in  nephrolithiasis  should  be  undertaken 
with  great  caution. 

Radiography. — Positive  findings  occur  in  all  but  10  per  cent,  of  cases 
and  may  be  regarded,  when  positive,  as  the  one  incontrovertible  proof 
of  renal  calculus.  It  is,  therefore,  yar  excellence  an  essential  in  the 
examination  of  all  renal  cases  with  pain. 

The  radiographic  work  must  be  carried  out  and  the  photographs 
interpreted  by  the  same  experienced  expert  so  that  due  familiarity  with 
the  conditions  of  the  laboratory  work  will  aid  in  interpretation  of  the 
plates  and  photographs. 

Leonard,^  of  Philadelphia,  who  finally  gave  up  his  life  to  his  devotion 
to  a:-ray  work,  formulated  the  following  conditions  of  a  successful 
renal  plate  which  are  now  accepted  without  question  in  about  the. 
following  terms: 

1.  The  eleventh  and  twelfth  ribs  must  be  distinctly  shown. 

2.  The  transverse  processes  of  the  lower  dorsal  and  lumbar  vertebrae 
as  wholes  must  show  plainly. 

3.  The  lateral  border  of  the  psoas  muscle  must  be  clear,  and  the 
shadow  of  the  muscle  itself  unmistakable. 

4.  The  kidney  shadow  must  be  sufficiently  distinct  to  reveal  the 
usual  outline  of  the  organ. 

Cole,^  however,  gives  the  basis  of  radiographic  diagnosis  as  follows: 
"One  is  not  justified  in  making  a  negative  diagnosis  of  renal  or  ureteral 
calculus,  unless  a  plate  of  the  renal  region  shows  the  following  detail: 
(1)  The  spine  and  transverse  processes  should  show  distinctly  all  the 
way  to  the  tip.  (2)  The  outer  border  of  the  psoas  muscle  must  show. 
In  some  very  flabby,  fat  patients  it  may  not  show  as  distinctly  as  the 
kidneys.  (3)  The  eleventh  and  twelfth  ribs  should  show  distinctly, 
and  in  many  cases  the  bony  detail  may  be  distinctly  seen.  (-1)  In  about 
75  per  cent,  of  the  cases  the  kidney  may  be  seen  more  or  less  distinctly, 

1  Quoted  by  Pilcher,  loc.  cit. 

2  New  York  Med.  Jour.,  190S,  Ixxxvii,  774. 


920    IN  FLA  MM  A  TIONS  OF  REN  A  L  PEL  1 7  N  .1  .V  D  PA  BENCH  YMA 

aiul  if  special  t-aiv  in  tcfhnic  is  used,  it  may  he  shown  in  nearly  every 
case.  (5)  Tlie  liA  er  is  frequently  seen,  and  at  times  it  interferes  with 
showing  the  convex  surface  of  the  U])])er  ])ole  of  the  right  kidney.  (G) 
The  spleen  also  may  be  seen,  especially'  if  it  is  enlarged  or  congested. 
(7)  Accumulation  of  gases  in  the  colon  and  small  intestnies  appears  on 
circmnscribed  areas,  and  folds  hi  the  walls  of  the  intestines  are  often 
seen  traversing  these  areas.  (8)  Feces  in  the  intestines,  especially  in 
the  colon,  show  very  distinctl\-,  and  interfere  \-er\-  materially'  with  the 
diagnosis  of  renal  lesions. 


Fig.  335. — Unusual  pyelogram.    Zebra  catlictcr  leading  to  large  dense  shadow  of  three- 
fold grouping  of  calyces  is  very  apparent.     (Author's  case.) 

Ureteral. — The  plate  of  the  ureteral  region  should  include  the  third, 
fourth  and  fifth  lumbar  vertebra^,  and  part  of  the  sacrum  ajid  iliinn. 
The  bony  detail  shoidd  show  distinctly  and  the  sacroiliac  synchojidrosis 
should  be  well  defined.  The  outer  border  of  the  psoas  muscle  is  clear, 
and  the  accumulation  of  gas  and  feces  is  frequently  seen  in  the  cecum 
or  sigmoid.  The  course  of  the  ureter  is  about  on  a  line  with  the  tips  of 
the  transverse  processes,  and  at  the  sacroiliac  synchondrosis.  Calcified 
arteries  are  sometimes  seen  in  the  plates. 

Pelvis. — ^This  plate  shows  the  pubes,  bony  structure  of  the  s])ine  of 
the  ischium,  sacrum  and  coccyx  all  the  way  to  the  tip.  The  bladder 
distended  with  urine  is  sometimes  well  marked,  also  \^'hen  injected." 


JJTIffASfS  OF  TIll'J  KIDNEY 


921 


Fig,  336. — Author's  special  obturator  of  the  Brown-Buerger  cystoscope  for  wax- 
tipped  catheter  test.  From  left  to  right  is  the  special  obturator  with  a  filiform  guide 
tied  in  the  slot  of  the  obturator  and  its  handle ;  the  naked  sheath  of  the  Brown-Buerger 
cystoscope;  the  old-style  obturator  without  slots  and  the  cystoscope  and  obturator 
assembled  with  a  filiform  guide. 


Fig.  337. — Multiple  phleboliths.  Nine  shadows  are  shown  in  close  or  remote  relation 
with  the  shadow  of  ureteral  catheters.  The  picture  is  from  a  woman  ha^■ing  gastro- 
intestinal disorders,  -with  renal  sjonptoms,  but  no  lesions.     (Author's  case.) 


922     IXFLAMMATinxs  OF  REXAL  PELVIS  AXD  PAREXCIIYMA 


Fig.  338 


Fig.  339 
FiG9.  338  and  339. — Author's  case  of  ureteral   calculus  descended  by  conservative 
treatment.    Fig.  338  shows  the  shadow  catheter  in  contact  with  the  stone  .situated  about 
one  inch  above  the  spine  of  the  ischium.     Fig.  339  details  progress  of  the  stone  to  a 
point  nearly  three-quarter  inches  below  the  spine  as  indicated  by  the  shadow  catheter. 


LITfllA.S/S  OF  THE  KIDNEY  923 

Diagnosis. — ^The  diagnosis  rests  on  the  following  })ases:  The  sub- 
jective findings  are  renal  colic  recurring  through  many  years  usually 
with  increasing  severity.  Blood  and  pus  in  the  urine  are  occasionally 
important.  The  objective  data  in  the  urine  are  dense  sediment  of 
oxalate  of  lime,  uric  acid  and  in  certain  conditions  phosphates,  micro- 
scopic and  gross  quantities  of  bloofl  and  pus,  and  renal  epithelium. 
Fragments  of  calculi  or  small  calculi  as  gravel  are  important.  I  reteral 
catheterism  is  relatively  not  difficult  in  the  absence  of  ureteral  disease. 
Last,  and  most  important,  a  series  of  .r-ray  plates  embracing  the 
kidney,  ureteral  and  bladder  zones.  Negative  .r-ray  plates  should  not 
be  regarded  as  final  unless  repeated  several  times  without  positive 
results. 

DifEerential  Diagnosis  involves  primarily  radiography  applied  not  only 
to  the  kidney  but  also  to  the  ureters.  Haenisch^  gives  the  following 
collection  of  errors  in  literature : 

1.  Enterolith  of  the  vermiform  appendix  (Weisflog^) . 

2.  Exostoses  of  the  ilium  (Koehler^). 

3.  Sesamoid  bone  in  the  tendons  of  the  obturator  muscle  (Caldwell^). 

4.  Carcinoma  (scirrhus)  of  the  head  of  the  pancreas  (CaldwelP). 
(Cole.) 

5.  Gall-stone  near  the  same  point  (Caldwell*^).     (Cole.) 

6.  Calcified  appendix  epiploica  (Brewer^). 

7.  Dense  fecal  scybala  (Koenig,  Jun.^).     (Haenisch.^) 

8.  Calcified  blood  clot  in  a  highly  degenerated  carcinomatous  kidney 
(Grosglik^) . 

9.  Calcification  of  a  segment  of  the  aorta  (Fenwick^") . 

10.  Masses  of  bismuth  as  medication  (Baetjer^^). 

11.  Masses  of  salol  as  medication  (Pancoast^'). 

12.  Penis  displaced  upward  upon  the  abdominal  wall  during  the 
radiography  (Kienboeck,^^  Blum^*). 

13.  Calcification  of  tuberculous  foci  in  the  kidney  (Straeter^^) . 

14.  S^Tnmetrical  calcification  of  the  vasa  deferentia  (E.  Fraenkel^^). 
(with  numerous  phleboliths  and  calcified  arterial  branch).  . 

15.  Chronic  induration  of  the  renal  parench\Tna  (Smart^^),  or  scar 
tissue  infiltration  (Baetjer^*). 

16.  Calcification  of  the  mesenteric  and  other  hmph  nodes 
(Fenwicki9). 

1  Rontgendiagnostik  des  Uropoetischen-systems,  1908,  pp.  15,  16  and  17. 
^  Fortschr.  a.  d.  Geb.  d.  Roentgenstrahlen,  1907,  x,  217. 

2  Correspondence,  Fortschr.  a.  d.  Geb.  d.  Roentgenstrahlen,  1907,  x,  295. 
^  Med.  News,  1905,  Ixxxvi,  761. 

5  Wrongly  given  by  Haenisch  as  Caldwell,  Med.  News,  1905,  lxxx^-i,  4-11. 

6  Ibid.  7  Med.  News,  1905,  Ixxx^-i,  760. 
8  Log.  cit  and  Koenig,  Jun.,  loc.  cit.  '  Monatsber.  f.  Urol.,  1906,  %-iii. 
»  British  Med.  Jour.,  1905,  i,  1325. 

■  Am.  Quar.  Jour,  of  Roentgenologj%  1907,  ii,  17. 

■  Remarks  in  Discussion,  Med.  News,  1905,  lxxx\-ii,  807. 
'  In  a  Society  Meeting  Report,  Milnch.  med.  Wchnschr.,  1907,  liv,  2208. 
^  Loc.  cit.  15  Verhandl.  d.  deutschen  Roentgengesellschaft,  1907,  iii,  90. 
6  Verhandl.  d.  deutschen  Roentgengesellschaft,  1907,  iii,  156. 
'  British  Med.  Jour.,  1905,  ii,  617.  i«  Loc.  cit.  "  Loc.  cit. 


924     IXFLAMMATIOXS  OF  REXAL  PKLVI.'^  AXD  PAREXCHYMA 

17.  Dense  cutaneous  scar  in  the  kidney  region,  es])ecially  in  the  back 
(Haenisch*). 

IS.  Defects  in  the  photographic  i)latcs  tliemselves.  (Bhim,-  and 
almost  all  other  authors). 

The  author  would  add : 

19.  Calcified  spots  in  tlie  lipnnents  in  the  spine  and  the  pelvis 
(Haenisch^). 

20.  Phleboliths,  especially  in  the  xciiis  or  the  ureter  and  pelvis. 
(Pancoast)     (Baetjer.'*) 

21.  Stones  in  the  prostate  (Haenisch^). 

22.  Lime  salts  in  purulent  focus  of  kidnc\'  ])clvis  (Baetjer®). 

23.  Sesamoid  bojies  in  great  sacrosciatic  ligament  or  muscles  (Cole''). 

24.  Mass  of  gravel  (Koenig*). 

25.  Tuberculous  gland  in  pelvis  of  kidney  (Koenig^). 

26.  Stains  of  thorium  in  the  kidney  substance  (Busby^").  Busby's 
case  occurred  in  the  siu'gical  service  of  one  of  the  large  hospitals  of  New 
York  City.  An  .r-ray  plate  has  proved  negatiAe  for  stone,  but  after 
a  thorium  injection  shadows  simulating  the  size,  form  and  position  of 
stones  a})i)eared  in  suljsequent  ])lates;  these  shadows  persisted  for  five 
days,  but  at  the  operation  of  nephrotomy  no  stones  were  found.  The 
nephrotomy  was  undertaken  in  the  theory  that  stones  previously 
invisible  had  been  stained  and  rendered  opaque  to  the  rays. 

Haenisch  in  the  foregoing  article  gives  his  own  experience  as  follows : 
AVith  Albers-Schoenberg  calcification  of  the  end  of  the  twelfth  rib 
(also  condensation)  apex  of  transverse  process  of  lumbar  vertebra% 
calcified  myoma,  extrauterine  pregnancy,  prostatic  calculi,  dermoid 
cysts,  calcification  of  the  media  of  large  arteries  (iliac  and  uterine) 
deposits  on  spine  of  ischium,  sacroiliac  ligament  (not  proved),  fecal 
calculi,  calculi  in  ureteral  diverticula,  phleboliths.  Nearly  all  the  fore- 
going list  have  plates  to  prove  the  diagnosis.  Haenisch  makes  mention 
of  many  plate  faults.  Most  writers  include  blemishes  in  the  plates 
themselves. 

It  is  to  be  noted  that  if  shadow  catheters  had  been  used  during  the 
.T-ray  examination  practically  none  of  these  errors  would  have  occurred. 
This  list  shows  that  it  is  nearly  wasted  time  to  make  .r-ray  photographs 
of  the  kidneys  and  ureters  without  the  shadow  catheters  extending 
from  bladder  to  kidneys.  The  ureters  in  a  marked  degree  and  the 
kidneys  in  a  less  notable  degree  are  not  constant  in  number,  form,  size, 
position  and  direction.  Many  of  these  anatomical  and  pathological 
variations  cannot  be  demonstrated  by  the  a;-ray  alone  even  with  the 
shadow  catheters.    Pyelography  is  the  next  step  of  the  demonstration. 

The  .T-ray  although  it  may  show  a  shadow  and  without  the  shadow 
catheter  may  even  strongly  suggest  that  it  may  be  in  the  ureter,  does 

I  Loc.  cit.  2  Wien.  klin.  Wchnschr.,  1907,  xlix,  1539. 

'  Loc.  cit.  •*  Loc.  cit.,  and  Pancoast  loc.  cit. 

'  Loc.  cit.  «  Loc.  cit.  '  Loc.  cit. 

*  In  a  discussion  of  a  paper,  Miinch.  med.  Wchnschr.,  1908,  Iv,  25.  '  Loc.  cit. 

'"  In  a  personal  verbal  report  before  the  Medical  Progress  Club,  New  York,  May,  1917. 


LITHIASrS  OF  THE  KIDNEY  925 

not  show  the  mobih'ty,  the  hemorrhagic,  the  purulent,  or  the  obstruct- 
ing quaUties  or  the  effect  of  the  stone  on  the  function  of  the  kidney. 
The  catheters  in  situ  permit  the  full  diagnosis  of  the  case  at  the  one 
sitting  and  at  the  one  expense  in  time  and  strength  for  the  patient. 

Of  this  long  list  it  is  obvious  that  all  those  conditions  which  may  be 
situated  anywhere  between  the  twelfth  rib  and  the  symphysis  pubis 
in  an  x-ray  plate  may  simulate  stones  in  either  kidney  or  ureter,  while 
those  lesions  which  are  necessarily  confined  to  the  general  level  of  the 
kidney  itself  resemble  lithiasis  therein  in  their  shadows  rather  than  in 
the  ureter. 


Fig.  340. — Diverticulum  of  the  bladder.     Zebra  catheter  is  coiled  in  the  diverticulum, 
while  bismuth  catheter  passes  up  the  ureter.     (Author's  case.) 

The  differential  diagnosis  is  focussed  on  the  subjective  s^Tiiptom, 
pain,  in  the  renal  colic,  which  must  be  distinguished  from  that  of 
cholelithiasis,  appendicitis,  ovarian  disease  and  locomotor  ataxia,  and 
is  interpreted  by  the  results  of  cystoscopy,  urinalysis  and  radiography. 

The  differential  diagnosis  in  other  renal  lesions  recognizes  acute 
pyelitis,  renal  tuberculosis,  renal  neoplasm,  renal  varLx,  renal  suppura- 
tion, lithiasis  of  the  ureters  and  bladder,  and  vesical  new  growth  as 
sources  of  error. 

Acute  pyelitis  differs  from  nephrolithiasis  in  sudden,  less  severe  pain, 
more  fixed  in  the  region  of  one  kidney  with  little  tendency  toward 
points  of  reference.  The  rapid  accumulation  of  urine  in  the  pelvis 
causes  greater  enlargement  and  tenderness  of  the  kidney  and  then  more 
acute  signs  of  septic  absorption,  rigors,  fever,  leukoc\i:osis  with  90 
per  cent,  polymorphonuclears.    Pyuria  is  always  present  with  pollaki- 


92()     IXFLAMMATIOXS  OF  REXAL  PELVIS  AXD  PAREXCHYMA 

iiria.  Hadioyraphy  is  negative  on  rei>eate(l  tests.  I'rinalysis  shows 
no  sediment  of  crystals  or  fragments  of  calculi.  I'reteral  catheterism 
is  unobstructed,  withdraws  pus-laden  urine,  and  lavage  of  the  pelvis 
and  other  treatment  completely  and  quickly  relieves  the  sym])toms. 

UriKil  tiihcrcuhhsis  diffrrs  from  ii('j)hr()llf}ii(tsi,s'  in  the  early  ai)pcar- 
ance  of  polyuria,  poUakiuria  and  dysuria.  Bacillus  tuberculosis  is 
found  by  bacteriology  and  animal  experimentation.  Cystoscopy  shows 
the  early  changes  in  ureter  and  bladder.  Subjective  symptoms  at 
first  very  indefinite  and  objective  symptoms  increase  in  severity  with- 
out interrui)tit)n. 

Pyuria  is  an  early  progressive  sign.  Calculus  forming  in  a  tuber- 
culous kidney  adds  its  findings  to  the  antecedent  tuberculosis. 

UcnaJ  ncopJa,sin  differs  from  ncphroJiihiasis'xw  the  bleeding,  the  tumor, 
tlie  pain  and  the  pus.  Hematuria  in  tumor  is  sudden  without  known 
exciting  cause,  copious  and  recurrent  as  the  one  prominent  symptom, 
and  usually  absent  even  microscopically  between  its  onsets.  No  bleed- 
ing like  this  occurs  in  nephrolithiasis  excepting  in  the  unusual  condition 
of  a  "silent"  stone  with  sudden  wounding  of  its  bed.  Usually  with 
stone  blood  is  constantly  present  in  microscoj)ic  (juantities.  P^nlarge- 
ment  of  the  kidney  in  tumor  is  much  more  manifest  and  when  dis- 
tinctly palpable  begins  to  cause  subjective  discomfort  and  pain  which 
are  devoid  of  colic,  except  the  rare  circumstance  of  the  passage  of  clots. 
Pus  in  the  urine  which  is  prominent  in  lithiasis  is  absent  in  neojjlasm 
of  the  kidney  unless  necrosis  of  tissue  is  present,  as  in  later  stages. 

Renal  varix  differs  fron  nephrolithiasis  much  as  does  neoplasm. 
Bleeding  is  the  one  competent  symptom  of  varix  without  other  signs 
of  kidney  involvement,  such  as  tumor,  pain,  pus,  urinary  sediment 
and  .r-ray  findings.  Changes  in  the  circulatory  pressure  as  on  arising 
in  the  morning  and  on  exercise  are  very  apt  to  excite  the  bleeding. 

Renal  suppuration  differs  from  nephrolithiasis  in  the  details  pre- 
viously described  under  the  headings  of  pyelonephritis  and  pyo- 
nephrosis. Stones  formed  in  the  kidney  secondary  to  these  conditions 
are  often  confusing  but  are  usually'  cleared  up  by  the  .r-ray  plates. 

Lithiasis  of  the  ureters  and  bladder  differs  from  nephrolithiasis  in  the 
manner  detailed  under  these  headings.  The  .r-ray  findings  in  the  former 
are  the  most  important  distinction.  Stone  in  the  bladder  should  be 
recognized  ordinarily  without  the  x'-ray. 

Vesical  new  growth  may  simulate  nephrolithiasis  by  the  immediate 
location  of  the  tumor  at  the  meatus  of  the  ureter  on  the  affected  side. 
It  is  only  such  cases  as  give  kidney  symptoms  through  obstruction  of 
the  ureter  but  without  any  of  the  characteristic  severity,  periodicity 
of  the  pain  and  urinary  conditions  of  stone  in  the  kidney  and  pelvis. 

Treatment. — Nephrolithiasis  requires  nonoperative  and  operative 
measures. 

The  nonoperative  or  medicinal  methods  are  piu'ely  preventive.  A 
patient  in  whose  urine  crystals  are  abnormal  and  persistent  in  quantity 
may  be  prevented  from  forming  a  true  calculus  by  suitable  diet, 
management  and  medication  and  similarly  in  a  less  successful  degree 


HEMORRIJAGE  FROM  THE  KIDNEY  927 

patients  who  have  passed  gravel  or  small  solitary  stones  hut  whose 
radiographic  picture  of  the  kidneys  shows  no  other  stone. 

The  operative  measures  alone  avail  if  the  kidney  is  the  seat  of  a 
primary  or  secondary  stone.  Even  primary,  uninfected  cases  should 
undergo  operation  because  the  presence  of  the  stone  sooner  or  later 
induces  infection,  after  which  the  kidney  may  no  longer  be  serviceable. 

Choice  of  operation  lies  between  the  conservative  measures  pyelo- 
lithotomy,  nephrolithotomy,  pyelorrhaphy  and  the  radical  operation 
nephrectomy. 

The  conservative  steps  are  undertaken  when  the  proportion  of  the 
stone  to  the  pelvis  and  its  relation  to  the  kidney  and  the  pelvis  make 
delivery  through  the  wall  of  this  cavity  or  the  organ  possible. 

Pyelolithotomy  is  suitable  for  primary,  uninfected  cases  in  which 
the  kidney  is  easily  deliverable  upon  the  flank  and  manageable  for  the 
division  of  the  pelvis,  delivery  of  the  stone  and  repair  of  the  field. 
A  reasonably  long  pedicle,  absence  of  adhesions  and  an  otherwise 
free  field  are  essential. 

Nephrolithotomy,  namely,  division  of  the  kidney  substance  along 
the  free  border  over  the  most  prominent  part  of  the  stone  or  through- 
out its  entire  length  according  to  indications,  should  be  undertaken 
when  the  condition  of  the  field  forbids  pyelolithotomy. 

Pyelolorrhaphy,  plastic  pelvic  repair,  may  be  added  to  either  of  the 
preceding  operations  in  the  endeavor  to  correct  any  pouching  or  other 
deformity  of  the  pelvis  which  may  invite  recurrence. 

Obese  subjects,  firmly  adherent  kidneys,  perinephritic  exudate, 
short  pedicles  deeply  implanted  within  the  kidney  substance  are  more 
or  less  serious  obstacles,  surmountable  by  long  experience. 

Nephrectomy  is  the  radical  operation  and  is  applicable  to  the  secon- 
dary infected  cases,  especially  those  showing  destruction  of  kidney 
substance  and  loss  of  kidney  function.  Conservatism  in  such  cases  is 
a  menace. 

Nephrorrhaphy,  namely,  suture  of  the  kidney  back  into  such  a  posi- 
tion as  will  secure  perfect  drainage  of  a  deformed  pelvis,  has  been  tried 
as  another  conservative  operation  with  some  success  after  a  recurrence 
of  the  stones. 

RARE  FORMS  OF  DISEASE  OF  THE  KIDNEY. 

Classification. — ^Rare  forms  of  disease  of  the  kidney  are  very  difficult 
to  classify  because  the  exact  pathogenesis  of  the  more  important 
examples  is  not  understood  thoroughly.  The  chief  diseases  of  interest 
under  this  title  are  asyndromic  hemorrhagic,  syndromic  hemorrhage, 
cystonephrosis,  and  renal  syphilis. 

HEMORRHAGE  FROM  THE  KIDNEY. 

Ssmonyms. — Hemorrhagic  disease  of  the  kidney,  essential  hemorrhage 
from  the  kidney,  symptomless  or  painless  hemorrhage  from  the  kidney, 


02S     IXFLAM.\[ATIOXS  OF  REXAL  PELVIS  AXD  PAREXCHYMA 

also  called  asyndroniic  hemorrhage  of  the  kidne\'  and  syndromic 
heniorrhnc:e  from  the  kidney. 

Definition  and  Varieties. — Hemorrhage  from  the  kidney  must  include 
the  asyndromic  or  symptomless  and  syndromic  or  symptomatic 
varieties  of  hemorrhage.  In  both  the  hemorrhage  is  so  cardinal  and 
important  as  to  be  a  pathological  factor.  The  idiojxithic  or  sjinptom- 
less  hemorrhage  is  not  a  part  of  a  syndrome  but  stands  alone  as  a  symp- 
tom witliout  antecedents  of  definite  character,  especially  of  subjective 
t\'])e.  The  syndromic  hemorrhage,  on  the  other  hand,  is  only  one  of 
many  important  symptoms  and  may  therefore  be  dismissed  from 
further  consideration  as  an  unclassified  renal  condition,  except  for 
comparisons. 

Etiology. — Hemorrhage  from  the  kidney  may  arise  in  any  of  the  fol- 
lowing conditions:  Irritation  due  to  drug  and  sometimes  ptomain 
poisoning  from  food.  Inflammation  as  acute  congestion,  acute  and 
chronic  nephritis,  tuberculosis  and  rarely,  suppuration.  Infectious 
absorption  as  in  the  exanthemata  of  childhood,  chiefly  in  the  type  of 
congestion,  degeneration  and  inflammation.  Traumatism  by  direct, 
partial  or  complete  rupture  of  blood\'essels  and  kidney  substance. 
Lithiasis,  by  attrition,  erosion  and  ulceration  of  bloodvessels.  Neo- 
plasm by  congestion,  ^■aricosities  and  ulceration,  ^'arix  by  back 
pressure  and  weakened  walls.  Entozoic  infection,  especially  filariasis 
and  distoma  hematobium  (Bilharz),  by  influence  on  vessels  and  ulcera- 
tion. 

Diagnosis. — Hemorrhage  from  the  kidney  is  recognized  by  the  un- 
usual quantity  of  blood  in  the  urine,  chiefly  macroscopic,  occasionally 
microscopic,  in  both  mixed  and  separated  specimens  obtained  through 
c>'stoscopy  and  ureteral  catheterization.  The  diagnosis  must  show 
the  origin  of  blood  to  be  renal.  Other  sources  of  bleeding  are  ureteral 
and  vesical. 

Hemorrhage  from  the  Urethra  Differs  from  Renal  Ilemorrhaf/e. — It 
is  usually  from  the  prostate  and  may  readily  be  recognized  by  the 
Wolbarst  five-glass  test  in  which  the  fourth  or  bladder  glass  will  be 
almost  entirely  free  of  blood  if  the  bleeding  is  from  the  prostate,  while 
the  third  or  posterior  urethral  glass  will  contain  much  blood.  Prostatic 
bleeding  is  also  terminal  and  usually  accompanied  with  other  prostatic 
symptoms,  both  subjective  and  objective.  Cystoscopy  shows  no  vesical, 
ureteral  or  renal  signs.  Urethroscopy,  if  possible,  reveals  a  severely 
congested  prostatic  neck  and  posterior  urethra.  The  separated  urines 
are  normal,  practically  identical  and  blood-free  on  microscopic  inves- 
tigation. 

Vesical  hemorrhage  differs  from  renal  hemorrhage  by  the  presence  in 
the  bladder  of  ulcer,  varix,  acute  inflammation,  calculus,  neoplasm  or 
other  direct  bleeding  points.  Active  vesical  bleeding  is  very  hard  to 
control  by  irrigation  of  the  bladder  for  cystoscopy,  blood  appearing 
so  quickly  as  to  darken  the  medium.  Preparation  of  the  bladder  in 
such  cases  indicates  administration  of  ergot  or  adrenalin  internally, 
mild  styptics  locally,  gentle  hot  lavage  without  frequent  repetition. 


PAINLESS  HEMATUIilA  FROM  THE  KIDNEY  929 

sedatives,  rest  in  bed,  and  few  fluids.  If  the  bladder  ceases  to  bleed 
temporarily  ureteral  catheterism  reveals  normal  urines  devoid  of  renal 
elements.  After  washing  and  distentions  of  the  bladder  rapid  and 
complete  emptying  will  frequently  excite  the  bleeding  anew.  The 
Wolbarst  five-glass  tests  will  show  the  fourth  or  bladder  glass  rich 
in  blood. 

ASYNDROMIC   OR  PAINLESS   HEMATURIA    FROM   THE  KIDNEY. 

Definition. — Painless  hematuria  from  the  kidney  recognizes  the  fact 
that  the  bleeding  occurs  apart,  by  and  apparently  of  itself,  being 
sometimes  called  essential  hemorrhage  from  the  kidney.  It  is  there- 
fore not  associated  with  a  syndrome  of  definite  character,  especially 
of  subjective  type.  A  diagnosis  is  made  possible  only  by  the  most 
careful  search  for  objective  signs  to  explain  the  underlying  condition 
which  frequently  may  not  be  recognized  until  operation. 

Painless  hemorrhage  from  the  kidney  is  the  accepted  terminology 
and  will  be  adopted  in  this  work  on  the  ground  that  pain  and  discom- 
fort in  urological  conditions  are  usually  the  first  noted  and  complained 
of  by  the  patient. 

Etiology.— Painless  hemorrhage  from  the  kidney  arises  chiefly  from 
irritant  poisons,  acute  and  chronic  nephritis,  varix  (Pilcher^  or  angioma 
(Fenwick"^),  benign  papilloma,  and  as  rare  exceptions,  malign  new 
growths  and  tuberculosis. 

Hemorrhage  in  the  course  of  cancerous  and  tuberculous  degeneration 
of  the  kidney  has  been  fully  discussed  and  needs  no  separate  subdivision 
under  the  topic  of  painless  hemorrhage  from  the  kidney. 

Diagnosis. — Painless  hemorrhage  from  the  kidney  involves  its 
recognition  between  and  during  attacks  of  bleeding. 

During  the  hemorrhage  cystoscopy  reveals  prompt  and  easy  cleans- 
ing of  the  bladder  from  blood  in  the  preparation  unless  the  flow  is 
extreme.  The  mouth  of  the  ureter  is  usually  little  affected  betw^een 
attacks  but  during  the  flow  jets  of  blood  from  it  appear  mixed  with  the 
urine.    The  bladder  as  a  whole  is  always  normal. 

Tuberculous  or  cancerous  ulcer  very  near  the  ureteral  mouth  may, 
by  its  own  bleeding,  mask  essential,  symptomless  renal  blood  but  the 
fact  of  the  ulcer  is  suggestive  and  ureteral  catheterism  will  aid  in  the 
diagnosis.  A  healthy  bladder  with  blood  spurting  from  one  ureter 
like  a  volcano  with  each  ureteral  contraction  or  oozing  idly  between 
the  contraction  is  strongly  suggestive  of  renal  hemorrhage.  Ureteral 
catheterization  with  separation  of  the  urine  shows  few  or  no  renal 
elements,  casts,  epithelia,  crystals  or  detritus,  as  in  nephrolithiasis,  and 
no  Bacillus  tuberculosis. 

Between  the  attacks  of  painless  hemorrhage  one  kidney  as  its  source 
is  difficult  to  recognize,  except  by  all  possible  means  of  diagnosis. 
There  may  be  no  very  definite  means  of  conclusion.    Signs  of  disturb- 

1  Practical  Cystoscopj^,  1911,  p.  357. 

2  Clinical  Cystoscopy,  1904,  p.  492. 
59 


930     IXFLAMMATIOXS  OF  REXAL  PELVIS  AXD  rAHEXCIIYMA 

ance  may  show  aliout  the  aH'ectod  ureter  in  the  bladder  immediately 
after  the  blood  has  stojiped. 

Toxic  Painless  Hemorrhage  from  the  Kidney.  -Varieties. — ^Toxic 
hemorrhage  from  the  kidney  includes  that  due  to  the  ini:;estionof  drugs, 
mineral  and  vegetable  ])oisons,  and  that  due  to  j^tomain  ])oisoning 
from  foods,  as  the  chief  classes. 

Diagnosis. — Toxic  hemorrhage  from  the  kidney  is  relatively  easy 
from  the  history  of  ingestion  of  drug  or  food  and  the  presence  of  severe 
nejihritis  associated  with  the  bleeding.  Some  of  these  cases  belong  to 
the  syndromic  form  as  the  nephritis  may  give  its  symptoms  before  the 
bleeding  ai)pears. 

Treatment. — Toxic  painless  hemorrhage  from  the  kidney  requires 
administration  so  far  as  possible,  of  chemical  and  physiological  anti- 
dotes and  elimination  of  the  offending  poison  and  then  the  usual 
management  and  treatment  of  the  damaged  kidneys  and  depressed 
constitution. 

Painless  Hemorrhage  from  the  Kidney  in  Acute  Nephritis. — 
Varieties. — Painless  hemorrhage  in  acute  nephritis  is  seen  in  con- 
gestion, degeneration  and  inflammation  of  the  kidney.  All  may  fully 
recover  with  a  normal  kidney  or  the  inflammation,  and  sometimes 
the  degeneration,  may  leave  a  damaged  kidney  with  progressing 
disease. 

Etiology. — Painless  hemorrhage  in  acute  nephritis  is  the  same  as  that 
of  the  nephritis  itself,  namely,  irritant  poisons  of  chemical  character 
or  of  the  infectious  diseases,  especially  in  childhood  and  the  intense 
congestion  of  overwork  in  generalized  burns  of  the  body. 

Subjective  and  Objective  Syndrome. — Painless  hemorrhage  in  acute 
nephritis.  Indei)endently  of  the  blood  itself  one  finds  frequency  of 
urination,  vesical  irritation,  decreased  quantity,  high  color,  raised 
specific  gravity,  considerable  albumin,  many  casts  and  epithelia. 

After  the  blood  has  appeared  it  may  alter  the  picture  by  its  micro- 
scopic or  macroscopic  quantities  and  frequency  of  urination  w'ith 
vesical  irritation  may  be  sudden  and  severe. 

Cystoscopy  offers  little  of  diagnostic  value.  If  the  bleeding  is  not 
so  severe  as  to  prevent  cystoscopy  altogether,  the  examiner  will  find 
the  hemorrhage  bilateral  although  one  side  may  be  more  active  than 
the  other. 

Painless  Hematuria  in  Chronic  Diffuse  Nephritis  with  Exudation. 
— Subjective  and  Objective  Syndrome. — This  form  of  nephritis  is  also 
known  as  parenchymatous  nephritis  and  commonly  shows  frequency 
of  urination  through  increased  quantity  of  urine,  specific  gravity  of  1010 
or  lower,  pale  color,  much  albumin,  all  varieties  of  casts,  excepting 
pus  casts,  and  much  renal  epithelia.  Blood  cells  are  added  in  attack 
from  microscopic  to  copious  quantities,  especially  if  any  cause  of  con- 
gestion supervenes. 

C}'stoscopy  between  the  attacks  is  negative  except  for  the  nephritis. 

During  the  attack  the  hemorrhage  is  shown  to  be  bilateral  as  a  rule 
although  one  side  may  be  the  more  active. 


PAINLESS  nEMATUIilA  IN  IIENAL  VAItlX  931 

Painless  Hematuria  in  Chronic  Diffuse  Nephritis  without  Exuda- 
tion.— Subjective  and  Objective  Syndrome.-  Ileiiai  arteriosclerosis  is  the 
other  term  applied  to  this  form  of  nephritis.  It  is  marked  by  increased 
quantity  of  urine  with  frequency,  pale  color,  specific  {gravity  of  1010 
and  less  and  no  albumin  or  casts,  or  a  faint  trace  of  albinnin  and  very 
few  casts. 

Bleeding  in  very  small  or  larger  quantities  may  be  added  in  attacks 
usually  associated  with  congestion  of  the  kidney  and  a  temporary 
reversion  of  the  nephritis  to  the  exudative  type,  showing  albumin  and 
casts. 

Cystoscopy  in  this  form  of  nephritis  is  the  same  as  that  in  the 
exudative  disease. 

Treatment. — Painless  hematuria  in  nephritis  is  the  same  for  the 
acute  and  both  chronic  forms.  The  nonoperative  measures  are  the 
recognized  management  and  need  no  description  in  a  work  of  this  kind. 

The  operative  measures  are  decapsulation  to  relieve  the  congestion 
and  pressure  on  the  essential  kidney  substance.  Nephrorrhaphy  may 
be  done  if  the  kidney  is  found  to  be  misplaced. 

Painless  Hematuria  in  Renal  Varix  (Pilcher)  or  Angioma  fFen- 
wick). — Fenwick  seems  to  have  been  the  first  to  describe  this  condi- 
tion, and  used  the  term  angioma.  Pilcher  was  the  first  to  use  the 
word  varix. 

Painless  hematuria  in  renal  varix  seems  to  be  the  best  term.  There 
are  various  other  terms  applied  only  to  the  varix,  namely,  telangiec- 
tasis, varix,  nevus,  angioma  and  varicosities. 

Pathogenesis. — The  pathogenesis  of  painless  hematuria  in  renal  varix 
is  not  definitely  known.  Such  factors  as  age,  sex  and  alcoholism  seem 
to  have  no  definite  relation  with  it.  The  condition  is  probably  analo- 
gous to  the  varicosities  found  in  the  saphenous,  hemorrhoidal,  spermatic, 
ovarian  and  gastric  veins,  or  similar  to  angiomata  and  nevi  of  the  sur- 
face of  the  body.  The  varix  is  unilateral,  no  bilateral  cases  appearing 
in  literature.  This  distinguishes  it  from  the  preceding  forms  of  renal 
hemorrhage  in  which  the  lesions  and  the  bleeding  are  bilateral,  such  as 
the  poisons  of  drugs,  foods,  infectious  disease,  nephritis,  hemophilia, 
malaria  and  the  like. 

Subjective  Syndrome. — Painless  hematuria  in  renal  varix  has  sys- 
temic and  local  s^Tuptoms. 

Systemic  symptoms  are  usually  absent,  the  general  health  is  unaf- 
fected unless  impaired  by  prolonged,  severe  bleeding. 

Renal  symptoms  show  more  subjective  sensations  in  the  opposite 
kidney,  as  a  rule,  which  must  take  up  more  duty  during  the  bleed- 
ing. The  blood  appears  suddenly  without  ascribable  cause,  such  as 
strain,  trauma,  nephritis,  infectious  disease,  drugs  and  colic.  Exertion 
usually  augments  while  rest  decreases  the  hemorrhage.  Pain  during 
the  hemorrhage  is  due  to  distention.  Ureteral  colic  is  absent  unless 
clots  are  being  passed,  which  is  not  the  rule  as  the  clots  in  this  condi- 
tion are  more  apt  to  form  in  the  latter.  Vesical  distention,  irritation 
and  pain  are  due  to  rapid  filling  of  the  viscus  with  blood  and  the  clotting. 


932     IXFLAMMATIOXS  OF  REXAL  rELVIS  AXD  PAREXCIIYMA 

Objective  Sjmdrome. — Painless  hematuria  in  renal  varix  requires 
j)hysical  examination,  cystoscopy  with  its  adjuvants  and  lahoratory 
analyses  for  its  objective  findings. 

Physical  examination  offers  but  little  unless  the  subjective  symp- 
toms are  severe  when  the  signs  of  the  normal  congested  kidney,  the 
distended  bleeding  kidney  and  the  tense  bladder  may  be  made  out. 

Cystoscopy  with  its  adjuvants  of  liematuria  in  renal  varix  reveals  a 
normal  bladder  with  blood  proceeding  from  one  ureter  on  inspection. 
Catheterization  of  the  two  ureters  gives  on  the  normal  side  unchanged 
urine  except  occasionally  for  the  signs  of  congestion  in  severe  cases. 
On  the  bleeding  side  much  all)umin,  due  to  the  blood  alone,  innumer- 
able red  cells  and  frequently  hemoglobin.  Pus,  epithelia,  casts,  crys- 
tals, fragments  of  stone,  gravel,  bacteria  or  Bacillus  tuberculosis  are 
all  absent.     Radiogni])hy  is  invariably  negative. 

Course. — Painless  liematuria  in  renal  varix  shows  a  recurrent  and  a 
remittent  type. 

Recurrent  cases  show  a  large  quantity  of  blood  for  a  few  days  which 
disappears  even  under  the  microscope.  After  a  period  of  perfect  health 
the  bleeding  recurs  in  the  same,  less  or  greater  degrees.  The  respites 
from  s}iuptoms  may  be  weeks,  months  or  years. 

Remittent  tx^pes  always  show  some  blood  under  the  microscope 
which  from  time  to  time  increases  to  large  quantities  with  a  periodicity 
similar  to  that  in  the  reciu'rent  cases. 

Diagnosis. — The  diagnosis  of  painless  liematuria  in  renal  varix 
considers  first,  the  kidney  as  the  source  of  blood,  excluding  the  urethra, 
prostate  and  bladder,  and  second,  cause  of  the  bleeding  as  far  as  possible 
w^hich,  however,  usually  extends  into  differential  diagnosis. 

The  subjective  history  is  suggesti\'e  in  gi\'ing  no  cause,  no  syndrome, 
especially  pain,  and  in  stating  a  sudden  onset  and  often  many  attacks. 

The  source  of  the  hemorrhage  is  located  with  the  five-glass  test  of 
Wolbarst  in  excluding  the  urethra  and  the  prostate  and  with  the 
urethroscope.  Cystoscopy  distinguishes  between  the  bladder  and  the 
kidney  as  the  bleeding-point.  If  there  is  much  blood,  prescribe  pre- 
liminary rest  in  bed,  morphin,  ergot  and  local  styptics  with  irrigation, 
which  in  bladder  bleeding  rapidly  stops  the  flow.  Ureteral  catheterism 
further  distinguishes  the  kidney  from  the  bladder  and  from  its  fellow 
as  the  source  of  hemorrhage. 

Differential  Diagnosis. — Painless  hematuria  in  renal  varix  is  finally 
determined  often  only  by  exploratory  operation.  It  should  distinguish 
the  bleeding  of  hemophilia  and  malaria  among  systemic  conditions 
and  nephritis,  tuberculosis,  calculus  and  neoplasm,  especially  hyper- 
nephroma and  i)apilloma  among  local  diseases. 

Painless  renal  htnnaturia  in  hemophilia  differs  from  varix  in  a  definite 
history  of  severe  bleeding  from  any  and  perhaps  all  the  mucous  mem- 
branes and  after  operation  or  accident.  Cystoscopy  shows  a  bilateral 
lesion. 

Painless  renal  hcinafnria  in  malaria  differs  from  rari.v  in  the  history 
and  in  the  finding  of  plasmodium  malaria  in  the  blood,  in  its  history 
and  commonly  in  the  bilateral  character  of  the  bleeding. 


PAINLESS  HEMATURIA    IN  PAPILLOMA  933 

Painless  renal  hematuria  in  nephritis  differs  from  varix  in  showing 
unmistakable  findings  of  nei)firitis  in  the  urine,  particularly  during  the 
period  of  quiescence,  as  during  the  bleeding  casts  are  very  hard  to  find. 
In  nephritis  with  constant  remittent  hemorrhage  and  in  varix  of  the 
same  type,  distinction  is  impossible  except  in  operation  in  some  cases. 

Painless  renal  hematuria  in  tuberculosis  differs  from  varix  in  revealing 
Bacillus  tuberculosis.  Its  bleeding  is  more  apt  to  be  microscopic  and 
is  rarely  in  floods,  as  in  varix.  Pus  and  r^nal  cells,  polyuria  and  pollaki- 
uria  are  in  some  degree  constant.  Cystoscopy  reveals  ureteritis  and 
cystitis  while  catheterism  is  characteristic  in  its  differences  between  the 
sides. 

Painless  renal  hematuria  in  calculus  differs  from  varix  in  its  urinary 
findings  of  sediment,  gravel  and  stone.  Colic  is  often  present  and  the 
x'-ray  settles  the  matter  in  90  per  cent,  cases.  Cystoscopy  indicates 
the  affected  kidney  and  the  passage  of  wax-tip  filiform  guides  or 
ureteral  catheters  is  of  service. 

Painless  renal  hematuria  in  neoplasm  differs  from  varix  in  occurring 
very  suddenly  and  usually  more  copiously,  and  in  always  recurring  at 
first  in  small  amounts,  later  in  large  amounts,  and  at  first  at  longer, 
then  at  shorter  intervals,  than  is  common  with  varix.  Renal  elements 
are  sometimes  present  and  cachexia  rather  than  anemia  is  a  feature. 
As  in  varix  there  is  at  first  no  nephritis  which  renders  the  distinction 
more  difficult.  Pain  at  first  absent  always  appears  later.  In  many 
cases  exploratory  operation  is  the  final  diagnostic  point. 

Treatment. — Nonoperative  measures  include  avoidance  of  possible 
exciting  causes  and  the  use  of  hemostatic  rest  and  lavage  of  the  kidney 
pelvis.  These  are  all  of  only  temporary  and  indeed  doubtful  value. 
The  operative  measure  of  choice  is  nephrotomy.  Temporary  ligature 
of  the  pedicle  makes  it  relatively  bloodless  so  that  the  kidney  may  be 
laid  open  from  end  to  end  and  its  pelvis  thoroughly  inspected.  This 
thorough  division  of  the  venous  lesion  into  halves  seems  to  reduce  the 
varicosities  permanently.  Nephrectomy  is  rarely  necessary.  Removal 
of  a  papilla,  the  seat  of  the  varix,  has  been  repeatedly  and  successfully 
done. 

Painless  Hematuria  from  the  Kidney  in  Benign  PapiQoma. — 
Occurrence. — Painless  hematuria  from  the  kidney  in  benign  papilloma  is 
a  very  rare  but  important  cause  of  asyndromic  renal  hemorrhage.  It 
is  almost  invariably  unilateral  only. 

Pathology. — Painless  hematuria  from  the  kidney  in  benign  papilloma 
shows  that  these  villous  neoplasms  have  decidedly  malignant  tendency, 
almost  always  recur  and  later  show  cancerous  change  and  degeneration. 
The  growths  are  solitary  and  pediculated  with  various  size  or  sessile 
and  extensive.  They  may  be  attached  to  any  point  of  the  pelvis  or 
at  the  ureteral  outlet  of  the  pelvis.  At  this  point  they  may  cause 
hydronephrosis  especially  of  the  hemorrhagic  t\T)e.  The  papillomata 
are  usually  primary  but  occasionally  secondary,  especially  to  nephro- 
lithiasis. Vesical  metastases  have  been  reported  but  are  rare  and  may 
mean  the  same  tendency  in  the  bladder. 


934     iyFLA}f}fATrO\S  OF  REXAL  PELVIS  AXD  PAREXCIIYMA 

Subjective  and  Objective  Syndrome.-  Painless  liematuria  from  the 
kidney  in  beniyn  papilloma  does  not  in  the  strict  sense  exist  until  the 
sudden,  luiexplained  bleeding  leads  to  an  examination.  The  cause  of 
the  blood  is  unknown  to  the  i)atient  except  for  some  minor  exciting 
factor.  Its  quantity  ^•aries,  being  usually  copious  and  like  the  onset 
its  disappearance  is  sudden.  Between  the  hemorrhages  there  are  no 
subjective  s.Muptoms. 

Physical  examination  is  negative  unless  the  hemorrhage  is  in  progress 
when  the  affected  kidney  may  be  large,  soft  and  shglitly  elastic  through 
tlie  retained  blood,  and  the  opposite  kidney  possibly  sensitive  from 
ordinary  congestion  and  overwork.  Urinalysis  is  negative  excepting 
for  the  blood,  as  in  the  primary  cases  there  is  neither  nephritis  nor 
pyelitis.  In  cases  secondary  to  stone  the  findings  of  this  condition 
may  occur.  Ureteral  catheterism  is  also  negative  excei)ting  for  the 
blood  from  one  side  in  the  primary  cases.  The  secondary  cases  with 
signs  of  nephrolithiasis  or  neoplasm  are  extremely  rare.  Functional 
tests  of  the  kidneys  are  also  negative  excepting  for  occasional  decrease 
directly  after  cessation  of  bleeding.    Radiography  is  negative. 

Diagnosis. — Painless  hematuria  from  the  kidney  in  benign  papilloma 
is  absolutely  known  only  at  operation  unless  a  fragment  of  papillary 
outgrowth  is  cast  off  and  secured,  which  would  be  a  very  rare  occur- 
rence. 

Treatment. — Painless  hematuria  from  the  kidney  in  benign  papilloma 
may  be  approached  conservatively  and  operatively.  Nonoperative 
measures  aim  to  control  the  hemorrhage  during  its  activity  by  rest 
in.  bed,  opiates,  ergot,  adrenalin,  and  the  like,  but  are  of  little  avail. 

Operative  measures  seek  to  remove  solitary  pediculated  papillomata 
without  infiltration  of  the  base  through  a  pyelotomy  or  nephrotomy  . 
after  temporary  closure  of  the  pedicle  of  the  kidney.    Nephrectomy 
is  necessary  in  the  recurrent  cases  and  for  sessile  infiltrating  papillo- 
matous growths,  which  are  almost  always  cancerous. 

Papillomata  of  the  bladder,  which  may  be  concomitants  or  metas- 
tases of  papilloma  of  the  kidney  pelvis,  should  be  treated  as  set  forth 
in  the  section  on  Vesical  Neoplasms. 

SYNDROMIC  HEMATURIA  FROM  THE  KIDNEY. 

Definition. — Syndromic  hematuria  from  the  kidney  is  a  term  w^hich 
simply  implies  that  the  bleeding  is -associated  with  and  subsequent  to 
other  subjective  and  objective  symptoms  of  the  disease,  of  which  it  is 
itself  only  an  added  symptom. 

Etiology  and  Varieties. — Syndromic  hematuria  from  the  kidney  is 
caused  by  renal  tuberculosis,  nephrolithiasis  ajid  renoAarix,  which  have 
been  already  discussed  under  the  heading  of  these  diseases  in  separate 
sections  and  under  the  heading  of  Painless  Hematuria  from  the  Kidney. 
These  three  conditions  will  therefore  need  no  further  discussion  under 
this  heading. 

The  chief  other  types  of  syndromic  hematuria  from  the  kidney  are 


HEM  Arum  A  IN  TRAUMATISM  OF  THE  KIDNEY  935 

those  caused  by  trauma,  aneurysm  of  the  renal  vessels,  necjplasm  and 
parasitic  disease  including  jiarticulariy  filaria  .sanf/uinis-  funninis  and 
distoma  hematohiuDi  (Bilharzi). 

Diagnosis. — In  the  diagnosis  of  syndromic  renal  hemorrhage,  bleeding 
which  is  only  part  of  a  symptom-complex  almost  always  has  a  character- 
istic ureteral  mouth. 

Tuberculosis  shows  signs  of  inflammation,  as  does  suppuratioji,  hoth 
of  definite  features.  Neoplasm  and  varix  of  the  kidney  rather  fre- 
quently reveal  congestion  and  edema,  with  prominent  bloodvessels 
through  circulatory  interference  and' a  tendency  to  patency. 

Nephrolithiasis  has  a  characteristic  urinary  discharge,  spasm  of  the 
ureter  with  strings  and  plugs  of  mucopus  and  renal  colic  present  or 
declining. 

Essential  hemorrhage  from  the  kidney  may  be  associated  with  any 
of  these  findings,  but  such  diseases  explain  the  cause  of  the  blood. 

Cystoscopy  offers  very  little  of  diagnostic  value  as  the  bleeding  is 
bilateral  and  the  patient  often  so  sick  as  to  make  the  cystoscopy  a 
profound  disturbance  and  inadvisable. 

Syndromic  Hematuria  in  Traumatism  of  the  Kidney.— Etiology. — 
Syndromic  hematuria  in  traumatism  of  the  kidney  is  caused  by  rupture 
of  the  intrinsic  vascular  system  of  the  kidney  by  direct  violence  of 
compression,  blows  and  falls,  or  by  indirect  violence  of  muscular 
exertion,  especially  of  the  trunk. 

Diagnosis. — Syndromic  hematuria  in  traumatism  of  the  kidney 
regards  a  sudden,  extremely  copious  hemorrhage.  The  history  reveals 
the  accident  or  the  muscular  exertion  and  the  objective  signs  are  those 
of  the  traumatism,  including  the  contusion  and  swelling  of  the  extra- 
renal blood  and  distention  of  the  bladder  with  blood  which  is  drawTi  off 
by  the  catheter.  Cystoscopy,  if  possible  at  all,  will  reveal  one  or  both 
kidneys  as  its  source.  The  hemorrhage  is  apt  to  be  for  some  time  too 
rapid  and  continuous  for  cystoscopy.  Ureteral  catheterism  with 
penetration  above  the  brim  of  the  bony  pelvis  is  usually  a  dangerous 
procedure  and  contraindicated  because  the  ureter  is  apt  to  be  damaged 
as  much  as  the  kidney,  and  later  because  accumulated  blood  clots 
mixed  with  the  urine  are  very  prone  to  mfection  even  without  the 
invasion  of  the  catheter.  Urinary  segregation  might  be  tried  in  some 
cases  and  found  of  value. 

The  diagnosis  of  the  fact  of  rupture  is  usually  frank  and  easy  but  a 
distinction  as  to  whether  one  or  both  kidneys  are  affected  sometimes 
renders  necessary  further  investigation  by  the  cystoscopist. 

Treatment. — Syndromic  hematuria  in  traumatism  of  the  kidney  has 
as  expectant  nonoperative  measures  the  same  as  all  other  forms  of 
internal  hemorrhage:  rest  in  bed  and  the  admmistration  of  copious 
ergot  and  other  hemostatics.  They  are  adopted  if  the  patient  is  not  in 
progressing  shock  from  loss  of  blood  and  contmue  until  the  hemor- 
rhage decreases. 

The  operative  measures  in  unilateral  cases  are  governed  by  the  last 
two  indications  just  named,  namely,  a  subsidence  of  both  shock  and 


936     IXFLAMMATIOXS  OF  liEXAL  PELVIS  AXD  PAREXCIIYMA 

lu'inorrhaije.    Xe})hn)t()iny  with  ]);u'kiiiu'  and  ])ivssur('  aiv  aAailablc  if 
the  kichiey  may  be  sa\e(l. 

Ureterorrhaphy,  or  repair  of  the  ureter  when  thnna^-ed  with  the 
kidney,  is  occasionally  possible. 

Nephrectomy  follows  continuation  of  tlu'  hemorrhage  or  infection. 
After  removal  of  the  kidney  tlie  bowels  and  the  skin  should  be  made  to 
aid  the  t>pposite  kidney  in  performinii;  the  body  function. 

Bilateral  extensive  trauma  of  tiie  kidney  necessarily  contraindicates 
all  interN-eiition. 

SjTidromic  Hematuria  in  Aneurysm  of  the  Renal  Vessels. — Occur- 
rence.— Aneurysm  of  the  renal  vessels  is  hi  the  ])edicle  of  the  kidney 
in  the  main  branches  of  the  renal  artery.  It  is  a  \ery  rare  condition. 
An  exact  diagnosis  is  made  only  on  the  pathological  table  after  operation. 

Etiology. — Ilematiu'ia  hi  aneurysm  of  the  renal  vessels  origuiates 
from  an  exciting  factor  ini])laiited  on  the  usual  causes  of  aneurysm, 
sclerosis,  tramnatism,  dilatation  and  perhaps  syi)hilis.  Disturbed  and 
congested  circulation  is  ])robably  the  source  of  blood  hi  the  urhie. 

Subjective  and  Objective  Syndrome. — Hematuria  in  aneurysm  of  the 
renal  vessels  is  variable,  uncertain  and  indefinite  and  presents  chiefly 
discomfort,  hematuria  and  tumefaction. 

Discomfort  or  pain  is  persistent  and  marked  or  totally  absent. 
Hematuria  is  acti^'e,  copious,  alarming  and  recurrent  after  periods  of 
rest  from  bleeding.  Tumefaction  can  hardly  be  made  out  easily  unless 
the  pelvis  of  the  kidney  happens  to  be  crowded  with  ])l<)od. 

Diagnosis. — The  diagnosis  of  hematuria  in  aneurysm  of  the  renal 
vessels  rests  on  the  history  or  traimiatism  or  other  cause  of  aneurysm, 
the  tumefaction  if  present,  and  the  hematuria.  The  urine  of  sclerotic 
kidney  may  be  present  and  arteriosclerosis  with  aneurysmal  tendency 
elsewhere  in  the  body.  An  exact  diagnosis  is  necessarily  impossible 
mitil  the  kidney  is  out  of  the  body. 

Cystoscopy  will  locate  the  affected  side  and  reveal  the  functional 
capacity  of  both  kidneys  and  foreshadow  the  results  of  operative 
treatment. 

Treatment. — The  treatment  of  hematuria  in  aneurysm  of  the  renal 
vessels  is  nephrectomy,  if  the  opposite  kidney  is  up  to  full  work. 
Durmg  the  actual  bleeding  the  usual  management  for  internal  hemor- 
rhage is  applicable.  In  inoperable  cases  medicinal  means  usually  em- 
ployed in  aneurysm  may  be  tried. 

Syndromic  Hematuria  from  the  Kidney  in  Filariasis.  —  Clinical 
Features. — Renal  infection  with  filaria  sanguinis  hominis  with  hema- 
turia occurs  in  the  inhabitants  and  travelers  of  the  tropics.  The  chief 
symptom  is  a  hematuria  with  or  without  a  chyluria.  The  bleeding  may 
appear  before  the  lymphatics  of  the  body  are  obviously  involved  as  in 
the  other  genito-urinary  organs. 

Diagnosis. — Decision  rests  on  finding  the  filaria  in  the  blood,  the 
iirhie  or  the  lymphatics. 

('ystosco])y  will  serve  to  reveal  the  invaded  lyTnphatics  of  the 
bladder  and  the  kidney  from  which  the  blood  is  proceeding. 


CYSTH  OF  THE  KIDNEY  937 

Treatment. — As  treatment  Pilcher'  aj^plicd  with  Ix'Ticfit  intravenous 
injection  of  salvarsan  to  his  patient,  who  ])resente(l  th(;  followinj^  feat- 
ures: chyluria,  hematuria,  })la(kler  free  from  lympliatic  varices,  normal 
phenolsulphonephthalein  reaction  and  only  left  renal  chyluria,  the  right 
kidney  secreting  normal  urine.    One  injection  seemed  to  cure. 

Syndromic  Hematuria  from  the  Kidneys  in  Bilharz's  Disease. — 
Occurrence. — Hematuria  from  the  kidneys  in  Bilharz's  disease  is 
limited  to  the  inhabitants  of  the  tropics,  most  commonly  of  Egypt,  or 
to  travelers  or  temporary  residents  there  who  have  returned  to  their 
native  land.  Thus  m  England  Eenwick  states  that  after  the  Egyptian 
and  South  African  campaigns  numerous  infections  were  found  among 
the  troops. 

Etiology. — The  etiology  of  hematuria  from  the  kidneys  in  Bilharz's 
disease  is  the  entozoon  distoma  hematobium  (Bilharzia)  and  the  ulcer- 
ative processes  it  produces. 

Subjective  Syndrome. — Hematuria  from  the  kidneys  in  Bilharz's  dis- 
ease is  that  of  renal  and  vesical  irritability.  Pollakiuria  is  prominent, 
the  hematuria  is  intractable,  the  vesical  irritability,  pain  and  cystitis 
are  finally  severe  and  the  urinary  changes  frequently  lead  to  vesical 
and  renal  lithiasis.  In  the  later  stages  anemia,  emaciation  and  pros- 
tration appear  and,  with  mixed  infection,  sepsis. 

Objective  Syndrome. — Hematuria  from  the  kidneys  m  Bilharz's  dis- 
ease has  invariably  a  severe  cystitis  on  cystoscopy,  showing  cyst-like 
bodies  m  which  are  the  ova.  Ulceration  and  rupture  follow  the  cysts 
and  the  discharge  of  the  ova.  The  bladder  is  in  a  generally  hemorrhagic 
condition  and  bleeding  from  one  or  both  kidneys  is  obvious.  There  is 
a  peculiar  gray  character  to  the  pus.  Stones  may  be  present  in  the 
bladder  or  ureters  or  kidneys. 

X-ray  examination  of  the  case  is  negative  unless  stones  are  present. 

Diagnosis. — ^The  diagnosis  of  hematuria  from  the  kidneys  in  Billiarz's 
disease  rests  on  the  history  of  traveling  or  residence  in  the  tropics  and 
the  cystoscopic  picture  and  most  important  the  detection  of  the  ova 
in  the  urine  and  feces.  Intestinal  hemorrhage  in  this  disease  is  very 
common  in  association  with  the  hematuria. 

Treatment. — The  measures  in  hematuria  from  the  kidneys  in  BOharz's 
disease  are  purely  expectant.    Very  little  seems  to  be  really  curative. 

CYSTS  OF  THE  KIDNEY. 

Synonyms. — Cysts  of  the  kidney  are  cystic  disease  of  the  kidney, 
cystic  degeneration  of  the  kidney,  nephrocysts,  cystonephrosis. 

Varieties. — Cysts  of  the  kidney  are  primary  or  idiopathic  without 
known  cause  or  antecedent  disease  of  the  organ,  and  secondary  to  some 
form  of  infection.  The  secondary  cysts  are  for  the  purposes  of  this 
work  not  important  as  they  do  not  change  the  condition  with  which 
they  are  associated. 

1  Medical  Record,  March  11,  1911. 


93S     IXFLAMMATIOXS  OF  REXAL   PELVIS  AXD  I'AREXCIIYMA 

Tlie  primary  cysts  aro  suhilivided  into  nionorysts  or  solitary  cysts 
an<l  ])olycysts  or  nmltiplc  cysts. 

Primary  Monocysts.  —  Pathogenesis.  —  Triniary  nioiiocysts  of  the 
kidney  arc  little  umlcrstood  and  arc  prohably  idio])athic,  without  known 
cause,  or  embryonal  throu<jh  defect  and  retention.  They  are  situated 
at  any  ])oint  or  pole  hut  the  laru'cst  .sccni  to  occur  at  the  lower  ])olc. 

Diagnosis.  Primary  nu)nocysts  of  the  kidney  are  jiot  tletcrmincd 
except  at  the  time  of  the  operation  unless  they  are  large  enough  to 
cause  symptoms  which  are  usually  those  of  pressure.  Cystoscopy  may 
show  a  ditference  between  the  two  sides  and  micover  a  hydronc})hrosis. 
INclomctry  and  .r-ray  are  of  serxicc.  Accidental  as])iration  of  a  cyst 
with  the  lu'cteral  catheter  is  possible  but  nuist  be  a  ^■ery  rare  occurrence. 
Deficiency  of  kidney  function  occurs  on  the  affected  side. 

Primary  Polycysts. — Pathogenesis. — Prima r>'  ]K)lyc\sts  of  the  kidney 
are  not  fully  understood.  Inlikt'  the  monocysts  they  are  very  rarely 
unilateral  but  commonly  bilateral  in  situation.  They  are  of  the 
eml)ryonal  retention  type,  as  a  rule,  but  may  be  acquired  freciuently 
in  association  with  cardiovascular  disease  and  anemia.  The  kidney  as 
a  whole  is  involved  and  more  or  less  in  a  condition  of  chronic  ne])hritis. 

Infection  is  often  secondarily  added,  giving  all  the  pathological 
findhigs  of  pyelonephritis  and  pyonephrosis. 

Symptoms. — The  subjective  syndrome  of  primary  polycysts  of  the 
kidney  is  summed  up  in  discomfort,  pain,  tumor,  frecpiently  displace- 
ment of  the  kidney,  various  reflex  gastro-intestinal  disturbances  and 
the  results  on  the  kidney  in  urinary  changes,  hematuria,  insufficiency, 
nephritis  and  chronic  uremia. 

In  the  objective  syndrome  of  primary  polycysts  of  the  kidney,  pal- 
pation reveals  enlargement,  sometimes  one  side  more  than  the  other 
but  almost  always  perceptible  on  each  side.  The  masses  are  of  irregular 
surface,  soft  consistency,  the  regular  normal  outlines  of  the  kidneys 
usually  without  tenderness  but  with  mobility  and  displacement. 

Cystoscopy  is  negative  as  to  the  bladder  but  ureteral  catheterization 
reveals  a  chronic  bilateral,  rarely  unilateral,  nephritis. 

As  the  disease  progresses  infection  almost  always  supervenes,  giving 
the  pictures  of  pyelitis,  pyelonephritis  and  pyeonephrosis. 

Diagnosis. — Primary  polycyst  of  the  kidney  is  frequently  found  at  the 
time  of  operation  only  particularly  in  the  iminfected  cases  which  have 
the  suggestive  characteristics  of  chronic  nephritis,  anemia,  sclerosis  of 
the  arteries,  cardiac  disease  and  soft  tumors  in  both  kidney  regions, 
of  which  one  may  be  slightly  larger  than  the  other. 

The  infected  cases  add,  of  course,  pus  from  one  or  both  ureters  on 
cystoscoi)>'  and  ureteral  catheterization  alike. 

Treatment. — Primary  monocysts  and  polycysts  of  the  kidney  must 
have  largely  the  expectant  treatment  and  management  of  chronic 
nephritis  if  the  function  of  the  kidneys  is  below  the  limit  of  safety 
for  operation. 

Xephre('tom\  is  the  o])eration  indicated  in  imilateral  disease  with 
the  other  ki(hie\-  doing  full  dutv  but  it  is  contraindicated  hi  bilateral 


HORSESHOE  KIDNEY,  FUSED  KIDNEY,  MULTIPLE  URETER     939 

disease.  For  this  reason  it  is  safe  always  to  expose  the  opposite  kidney 
if  at  the  operation  one  is  found  to  be  polycystic. 

Echinococcus  Renal  Cysts. — Pathogenesis.  —  Eehinococcus  renal 
cysts  have  a  rare  association  with  echijiococcus  infection  elsewhere  in 
the  body.  The  cysts  are  solitary  or  multiple  mother  cysts  containing 
the  usual  multiple  daughter  cysts. 

Syndromes  and  Diagnosis. — Echinococcus  renal  cysts  are  not 
specially  definite,  resembling  mainly  primary  monocysts  in  their 
symptoms,  signs  and  results.  Reflex  symptoms  and  slow  tumefaction 
are  present.  The  booklets  in  the  urine  would  fix  the  diagnosis  but  the 
mother  and  daughter  cysts  may  not  open  into  the  urinary  stream. 

Treatment. — The  treatment  of  echinococcus  renal  cysts  is  nephrec- 
tomy unless  the  disease  is  bilateral.  Removal  of  the  cyst  without 
rupture  by  nephrotomy  might  be  tried  in  selected  cases. 

SYPHILIS  OF  THE  KIDNEY. 

Pathogenesis. — Syphilis  of  the  kidney  is  in  the  form  of  nephritis, 
usually  bilateral,  occasionally  unilateral,  during  the  first,  second  or 
third  stage  of  the  disease,  or  in  the  form  of  gumma  in  late,  neglected 
cases. 

Diagnosis. — The  diagnosis  of  syphilis  of  the  kidney  rests  on  the 
history  of  syphilitic  infection  and  usually  of  somewhat  indifferent  treat- 
ment, on  the  positive  complement  fixation  tests  of  Wassermann  and 
Noguchi  in  the  blood,  and  on  the  characteristic  condition  of  the  spinal 
fluid. 

Cystoscopy  and  ureteral  catheterization  will  distinguish  one  kidney 
as  more  affected  than  the  other. 

A  most  important  diagnostic  aid  is  rapid  improvement  under 
treatment. 

Treatment. — S\'philis  of  the  kidney  requires  the  treatment  of  any 
other  important  visceral  involvement,  namely,  the  best  possible  manage- 
ment and  the  liberal  administration  of  mercury,  iodid  of  potash  and 
salvarsan. 

HORSESHOE    KIDNEY,    FUSED    KIDNEY,    UNILATERAL    KIDNEY 
AND  MULTIPLE  URETER. 

These  anomalies  are  rather  common,  especially  if  systematically 
looked  for.  Three  ureters  are  by  no  means  unusual  with  two  on  one 
side  and  one  on  the  other  side.  The  supernumerary  ureter  is  usually 
lower  in  the  bladder  and  higher  in  the  kidney,  as  is  the  fact  in  the  case 
of  the  author  sho'wn  in  Fig.  249.  Four  ureters  are  very  rare  but  have 
been  reported.  One  of  the  best  examples  of  unilateral  kidney  which 
the  author  knows  is  detailed  in  the  case  of  Dr.  Smith  and  pictured  in 
Fig.  343. 

History  of  Dr.  F.  W.  Smith's  case  (Figs.  341  and  342) .  IMale,  twenty- 
four  years  of  age,  complained  of  more  or  less  constant  aching  in  the 


940     IXFLAMMATIOX,'^  OF  REXAL  PELVIS  AND  PAREXCIIYMA 

right  sido.  atrgravatiHl  by  inovt'iiu'nt  and  V(>lii'\t'(l  hy  rest;  t)ccasio]ially 
referred  to  the  bhidder  neck,  scTDtuiu  and  tlie  right  thigh.  Various 
other  s\Tnptoms  for  want  of  etiology  would  be  classified  as  neurasthenia 
or  psychasthenia.  These  are  chiefly  epigastric  pain  and  burning, 
unconnected  with  taking  fiHHl;  eructations  and  a  feeling  of  distention 


Fig.  341 


Fig.  342 


Fig.  343 
FiG.s.  341,  342  and  343. — Displaced  fused  right  kidney.  Fig.  341  is  the  pyelogram 
of  the  double  pelvis;  Fig.  342  is  the  ureteral  catheters  passing  up  to  the  kidney  of  which 
one  has  not  penetrated  all  the  way;  Fig.  343  is  the  ureteral  catheters  in  the  bladder 
showing  the  nearly  normal  arrangement  of  the  openings  of  the  ureters  and  the  sudden 
divergence  toward  the  right  side  of  the  left  ureter.  There  is  no  left  kidney.  (Case  of 
Dr.  F.  W.  Smith.') 

of  the  stomach;  constipation  and  flatulence  of  the  colon;  vertigo, 
depression,  palpitation  and  various  fleeting  neuralgic  pains.  The 
patient  gave  a  history  of  an  injury  received  in  Russia,  when  eighteen 
years  of  age  and  a  driver.  When  turning  on  a  narrow  road,  he  raised 
the  rear  wheels  and  then  threw  the  wagon  around  and  felt  severe  pain 


'  Personal  communication  to  the  author,  1917. 


HORSESHOE  KIDNEY,  FUSED  KIDNEY,  MULriPLE  UliETER     941 

In  the  right  side  and  heard  a  cracking  sound  which  he  imitated  by 
pulling  his  finger.  He  immediately  became  faint,  vomited  and  was 
unable  to  stand  or  walk.  He  was  placed  in  the  wagon  and  taken  home. 
Each  jolt  of  the  wagon  increased  his  pain.  He  was  confined  to  his  bed 
and  home  for  two  months.  Since  then  he  has  been  ailing,  and  able  to 
do  only  the  lightest  kind  of  work. 

Prior  to  the  accident  he  was  well  ajid  strong,  and  no  predisposing 
factors  could  be  ascertained  from  past  illnesses  orcongenital  or  inherited 
taint.  Furthermore  there  had  never  been  anything  to  suggest  an  ano- 
malous or  misplaced  kidney. 


Fig.  344  Fig.  345 

Figs.  344  and  345. — Movable  kidney.  Fig.  344  shows  the  patient  in  the  Ij-ing-down 
position  with  small  flexible  ureteral  bougies  in  place  (Bugbee's  method)  and  the  kidneys 
normally  situated.  Fig.  345  figure  shows  the  same  patient  in  the  erect  position  wdth 
both  kidneys  displaced,  especially  the  left.  The  influence  of  respiratory  movement 
on  the  bougie  is  shown  on  the  left  side,  where  two  shadows  of  the  bougie  are  shown. 
(Author's  case.) 


Examination  showed  a  poorly  nourished,  undersized  man,  with 
stooping  walk  and  posture,  the  right  shoulder  considerably  lower  than 
the  left,  the  dorsal  spine  a  scoliotic  and  convex  to  the  left,  and  a 
slight  compensatory  curve  in  the  cervical  region,  the  abdomen  was 
prominent,  and  a  reniform  mass  could  be  determined  to  the  right  and 
below  the  umbilicus.  Varicose  veins  were  in  the  right  leg,  probably  due 
to  pressure  by  the  tiunor.  The  patient  had  no  urmary  s}-mptoms. 
Cystoscopy  showed  no  pathologic  lesions  in  the  bladder.  The  ureteral 
orifices  were  normally  placed,  and  the  trigone  was  s^Tametrical.  The 
separated  urines  were  about  equal  in  amount,  and  the  findings  showed 
that  each  kidney  was  functionating  properly  and  that  there  was  no 
abnormal  content  in  the  urine.  The  phthalein  output  also  was  about 
equal:  10  per  cent,  on  the  right,  and  12  per  cent,  on  the  left  in  the  first 


942    I^'FLA^f^fATIOXs  of  hexal  pelvis  axd  parexciiyma 

hour.  The  appearance  time  was  three  minutes  oji  the  left,  and  four 
miinites  on  the  right  side  after  the  intra^•enolls  injection. 

Opaque  bougies  were  passed  up  each  ureter  and  tJie  roentgenogram 
showed  that  tlie  left  ureter  crossed  the  middle  line  iji  front  of  the  fifth 
huiihar  Nertebra.  Thorium  i)yelograms  show  a  tandem  elVect.  The 
kidneys  are  on  the  same  side,  one  ]K>lvis  is  directed  outward  and  the 
other  toward  the  vertebral  column.  The  right  ureter  is  (lis])lac(Ml  out- 
ward.   The  left  is  shorter  than  the  riglit. 

The  operation  showed  an  unusual  end-to-end  fusion.  The  injury 
doubtless  caused  dislocation  and  the  lower  kidney,  by  jn-essure  on  the 
iliac  vessels  at  the  pelvic  brim,  jirobably  caused  the  gastro-intestinal 
sym])toms,  pain,  varicose  veins,  etc.  The  kidney  showed  the  usual 
lobulations  of  a  congenital  misplaced  kidne>'. 

The  entire  mass  was  raised  about  two  inciics  and  the  lower  ])art 
lifted  out  of  the  pelvis  and  anchored  to  the  dorsal  nuiscles. 

Very  instructive  contributions  to  the  subjects  of  horseshoe  kidney, 
fused  kidney,  unilateral  kidney  and  multiple  ureter,  have  been  made 
in  this  coimtry  by  Gould,'  Descherd,'  Levison,^  Cecel,^  Braasch,^ 
Stein"  and  others. 

'  Am.  Jour.  Med.  Sc,  1903,  cxxv,  428. 
2  Ibid.,  1904,  cxxvii,  104. 
=  .lour.  Am.  Med.  Assn.,  1904,  Ixii,  1354. 
*  California  State  Jour.  Med.,  1915,  xiii,  34. 

5  Pyelography,  1915. 

6  Am.  Jour.  Obst.,  191G,  Ixxiii,  462. 


CHAPTER   XVII. 

DISEASES  OF  THE  PROSTATE. 

Varieties. — Diseases  of  the  prostate  are  hypertrophy  of  the  prostate, 
catarrhal  and  suppurative  chronic  prostatitis,  tuberculous  prostatitis, 
neoplasm  of  the  prostate,  and  contracture  of  the  neck  of  the  bladder 
without  hypertrophy  of  the  prostate  but  with  symptoms  of  prostatism. 
All  are  of  interest  to  the  cystoscopist  and  will  be  briefly  described  from 
that  standpoint. 

HYPERTROPHY  OF  THE  PROSTATE. 

Subjective  and  Objective  Syndromes. — ^Hypertrophy  of  the  prostate 
is  so  variable  in  its  manifestations  as  to  be  beyond  the  limits  of  para- 
graphs on  technical  cystoscopy.  The  influence  of  the  senile  changes 
of  the  prostate  on  the  bladder  and  later  on  the  kidneys  makes  the 
consideration  of  the  subject  in  this  part  of  the  work  more  fitting  than 
in  the  part  devoted  to  vesical  condition. 

Cystoscopic  Examination. — In  hypertrophy  of  the  prostate  cystoscopy 
is  one  of  the  greatest  modern  diagnostic  advances.  On  account  of  the 
changes  in  form,  direction,  diameter  and  length  of  the  prostatic  urethra, 
the  short  beak  lateral  vision  cystoscopes  are  best,  such  as  the  Otis 
inspection  cystoscope,  the  Brown-Buerger  cystoscope  and  the  Acmi 
close-field  cystoscope.  Instruments  giving  lateral  vision  and  either 
inverted  or  corrected  images  may  be  used  according  to  the  familiarity  of 
the  cystoscopist.  Pilcher^  has  recently  described  a  close-vision  lateral 
field  concave  catheterizing  cystoscope  which  is  also  serviceable. 

Acmi  subcaliber  13  F.  and  18  F.  convex,  close-vision,  lateral  field, 
irrigating,  noncatheterizing  cystoscopes  are  of  inestimable  value  in 
these  cases  with  narrow  urethrse. 

The  Buerger  cystourethroscope  is,  when  its  passage  is  possible, 
available  for  studying  the  neck  of  the  bladder  and  of  the  prostatic 
urethra. 

Technic  of  Cystoscopy. — The  use  of  the  cystoscope  m  h^^Dertrophy 
of  the  prostate  includes  the  preparation  of  the  patient,  the  bladder  and 
the  details  of  the  examination  itself. 

The  preparation  of  the  patient  on  account  of  the  advanced  age 
usually  found  requires  rest  in  bed  for  at  least  twenty-four  hours  before 
and  after  the  examination,  internal  urinary  antiseptics  for  several  days 
previously  and  subsequently,  full  examination  of  twenty-four  hour 
specimens  of  urine  and  when  allowable,  the  use  of  opiimi  suppository. 

1  Practical  Cystoscopy,  p.  66. 


944  DISEASES  OF  THE  PROSTATE 

If  tlie  kidneys  are  in  a  state  of  advanced  nephritis,  pyelitis,  or 
pyonephrosis,  this  slioidd  be  revealed  by  a  competent  urmalysis,  but 
cystoscopy  is  contraindicated. 

The  position  of  the  patient  during  c>-stoscopy  for  hypertro]>hy  of  the 
])rostate  must  be  one  of  comfort  so  that  subsecjuent  clian,ue  and  incon- 
venience will  be  avoided. 

Moderate  universal  flexion  is  the  position  of  choice  for  most  patients. 
The  next  choice  is  the  moderate  lithotomy  position.  Some  patients 
are  more  comfortable  with  the  lower  extremities  hanging  lax  at  the 
sides  over  the  end  of  the  table  to  which  the  pelvis  has  been  drawn. 
AVhen  the  pelvis  is  raised  to  meet  the  eye  of  the  cystoscopist  the  patient 
must  not  experience  inconvenience.  For  this  reason  the  head  had  best 
be  high  on  pillows  or  table-top.  Change  hi  the  position  for  elevation 
of  the  pelvis  nuist  also  be  accomplished  without  alteration  of  the  parts 
to  be  examined. 

The  preparation  of  the  urethra  and  bladder  for  cystoscopy  in  hyper- 
trophy of  the  prostate  is  the  same  as  in  all  other  forms  of  irritable,  septic 
CNstitis  and  should  respect  kno\\'ledge  of  urethral  caliber,  length  and 
form.  Most  patients  will  accept  a  Ki  V.  or  IS  Y.  coude  catheter,  (hher 
forms  which  may  be  tried  are  the  bicoude,  olivary  straight  and  oli^'ary 
coude  and  bicoude.  Catheters  are  made  m  these  types  both  circular 
and  o\al  hi  cross-section.  The  cystoscojjist  should  be  familiar  with 
them  all,  and  select  that  which  causes  the  patient  least  discomfort. 
Irrigation  of  the  urethra  prior  to  exploration  is  a  wide  precaution. 

The  residual  urine  is  determined  in  the  following  manner:  The 
patient  makes  deliberate  effort  to  evacuate  his  bladder  in  both  standing 
and  kneeling  ])ositions,  "on  all  fours."  The  catheter  is  then  gently 
hiserted  imtil  free  flow  is  secured  ^^'hich  is  received  into  a  graduate. 
After  this  flow  has  stopped  the  catheter  is  advanced,  withdrawn, 
rotated  and  otherwise  manipulated  m  the  bladder  until  no  more  urine 
is  obtained.  The  quantity'  now  in  the  glass  is  the  residual  urine.  This 
reading  shoidd  be  verified  by  filling  the  bladder  with  a  measured  quan- 
tity of  warm  2  per  cent,  boric  acid  water  up  to  the  limit  of  slight  pain, 
which  will  reveal  the  capacity  of  the  bladder.  The  patient  now  evacu- 
ates this  fluid  in  the  same  manner  as  he  did  the  urine,  whose  force 
indicates  the  muscular  power  or  tonicity  of  the  bladder  wall.  The 
catheter  will  now  withdraw  the  residual  fluid  whose  quantity  should 
be  practically  identical  with  that  of  the  residual  urine,  previously 
obtained. 

The  length  of  the  urethra  is  indicated  by  the  folk)wing  procedure: 
At  the  moment  when  free  flow  appears  through  the  catheter  its  eye  is 
full\'  within  the  caA'ity  of  the  bladder.  The  penis  is  now  released  from 
the  hand  and  soon  comes  to  rest  on  the  catheter  at  a  point  which  may 
be  marked  conveniently  with  an  elastic  band.  When  the  catheter  is 
withdrawn  the  distance  between  its  eye  and  the  elastic  band  is  taken  to 
indicate  the  length  of  the  urethra,  which  may  be  greatly  increased  over 
the  normal  eight  inches. 

The  irrigatioji  of  the  bladder  is  now  begun  with  warm  2  per  cent. 


HYPERTliOl'HY  OF  THE  I' HOST  ATE  945 

boric  acid  water  through  the  catheter  placed  where  its  ev^acuatinj?  power 
is  best.  The  flushing  is  continued  until  the  fluid  is  clear  or  nearly  clear. 
It  is  impossible  to  remove  shreds  from  the  fiuid  but  these  do  not  obscure 
the  view  if  there  is  no  free  pus.  The  judicious  use  of  alum  water  will 
in  some  cases  temporarily  check  the  pus  so  that  a  clear  field  is  ob- 
tained. 

The  anesthesia  of  the  urethra  and  bladder  is  secured  by  instilling 
warm  2  to  5  per  cent,  solution  of  alypin  in  water  into  the  bladder. 
The  catheter  is  now  withdrawn  until  flow  stops,  when  thin  alypin  jelly, 
5  per  cent.,  is  forced  through  the  catheter  and  distributed  along  the 
urethra  from  point  to  point  as  the  catheter  is  withdrawn.  All  the  jelly 
is  carried  out  of  the  catheter  if  the  emptied  syringe  is  filled  with  air 
and  again  emptied  through  the  catheter.  The  penis  is  now  held  up- 
right by  the  patient  or  nurse  for  from  five  to  fifteen  minutes.  At  the 
end  of  this  time  anesthesia  is  completed.  Cocain  in  the  urethra  in 
these  cases  is  highly  undesirable  although  some  authors  teach  that 
cocain  absorption  will  not  occur  if  its  solution  is  put  into  the  urethra 
first  and  massaged  backward  along  the  canal  with  the  hand,  meaning, 
of  course,  that  catheter  instillation  of  it  may  traumatize  the  mucous 
membrane  and  excite  absorption.  Previous  administration  of  morphin 
is  said  to  be  a  physiological  antidote  of  cocain  intoxication. 

Bodine,^  who  was  in  America  one  of  the  pioneers  of  cocain  instilla- 
tions in  major  surgery,  uses  morphin  in  this  manner. 

Insertion  of  the  Cystoscope. — In  prostatic  hypertrophy  all  instrumen- 
tation should  always  be  bimanual  in  order  to  reduce  traumatism.  The 
following  method  will  be  found  of  great  service:  With  the  penis  held 
vertical  the  instrument  is  passed  gently  to  the  bulb  of  the  urethra.  The 
finger  is  now  inserted  into  the  rectum  and  curved  forward  to  meet  the 
tip  of  the  cystoscope  which  rests  on  and  turns  on  the  finger  and  then 
passes  across  it  to  the  apex  of  the  prostate  where  it  is  again  stopped 
until  the  finger  may  be  slid  along  the  cystoscope  to  the  same  pomt. 
The  finger  now  guides  the  tip  of  the  cystoscope  into  the  prostatic 
urethra  and  if  needed  steadies  the  prostate  itself  as  far  as  possible.  By 
this  procedure,  as  a  rule,  the  most  accurate  possible  passage  along  a 
tortuous  canal  is  usually  rendered  rather  easy. 

Estimation  of  Prostatic  Thickness. — After  the  instrument  is  in  place, 
the  rectal  finger  may  be  used  to  explore  the  prostate  as  it  lies  around 
the  cystoscope.  This  investigation  will  give  a  satisfactory  estimate  of 
the  thickness  of  the  prostatic  hypertrophy  projecting  backward  toward 
the  rectum  from  the  urethra.  The  thickness  of  the  prostate  projecting 
in  front  of  the  urethra  toward  the  symphysis  cannot  be  known  before 
operation. 

>  "My  dear  Dr.  Pedersen.     You  are  quite  correct  in  regard  to  the  morphin  before 
cocain  operations.     It  is  invariably  our  custom  in  hernia  operations  to  give  one-fourth  of 
a  grain  of  morphin  hypodermically  thirty  minutes  before  beginning  the  operation.     We 
look  upon  it  as  of  the  greatest  importance  in  preventing  cocain  sjTnptoms. 
With  best  wishes  always,  I  am 

Yours  sincerely, 

(Signed)  Johx  A.  Bodixe." 
60 


940  DISEASES  OF  THE  PROSTATE 

On  account  of  the  irritability  of  the  Madder  in  prostatic  hypertrophy, 
it  is  usually  better  to  leave  a  small  quantity  of  irrij^ating  Huid  m  the 
viscus  wliich  may  be  evacuated  and  replaced  or  increased  through 
the  sheath  of  the  instrument  as  needed.  In  this  way  the  beak  of  the 
instrument  does  not  touch  the  bladder  at  any  point. 

Cystosco})es  without  obturators  like  the  (^tis  ins])ecti()n  cystosco])e 
had  best  be  inserted  \\  ith  the  lens  turned  out  of  the  fenestrum,  in  order 
to  avoid  smearing  them  w  ith  blood.  When  the  telescope  is  ^^  ithdrawn 
for  the  distention  of  the  bladder  the  objective  lens  had  best  be  inspected 
in  order  to  be  sure  that  no  blood  has  covered  it. 

Xo  force  during  exploration  of  prostatic  hypertro])hy  in  the  insertion 
of  the  cystoscope  or  other  histrumcjit  should  CAcr  be  used  (1)  because 
of  traimiatism  and  the  danger  of  septic  absorption  through  opened 
lym])hvessels  and  bloodvessels,  and  (2)  because  of  the  secondary 
edema  of  the  ])rostate  with  obstruction  of  the  urethra  of  rather  obsti- 
nate degree,  (icntleness,  deliberation  and  precision  should  be  used 
as  the  contraries  of  force,  haste  and  uncertainty  in  technic. 

Clinical  Details  of  Cystoscopy. — Hypertrophy  of  the  prostate  concerns 
the  main  subjects  of  the  bladder  as  a  whole  and  of  the  prostatic 
protrusions. 

The  bladder  as  a  whole  is  studied  as  to  its  four  segments — lu-etero- 
trigonal,  subperitoneal,  urachal  and  retropubic  and  in  each  of  these 
subdivisions  as  to  inflammation,  trabeculations,  sacculations,  diverti- 
cula, deformities,  especially  of  the  retroprostatic  ])ouch,  and  stones. 

The  ureterotrigonal  segment  of  the  l)ladder  is  the  first  exj)l()red 
because  it  overlies  the  prostate,  may  be  much  affected  by  changes  in 
the  gland  and  imperfectly  studied  in  the  short  time  allowed  by  the 
irritable  bladder.  As  in  the  method  described  by  the  author  under  the 
subject  of  technic  in  cystoscopy,  after  the  air  bubble  at  the  highest 
point  of  the  bladder  has  been  recognized,  the  instrument  is  rotated 
through  ISO  degrees  to  the  middle  line  of  the  fundus,  in  which  it  is 
ad^-anced  or  withdrawn  until  the  interureteric  fold  is  located.  This  is 
then  studied  along  with  the  ureteric  fold.  The  ureters  are  observed 
for  size,  deformity',  normal  and  abnormal  discharge  of  urine,  and  the 
presence  of  mucus,  pus  or  blood. 

Meatoscopy  is  difficult  because  of  the  prominence  of  the  prostatic 
body.  Over  this  the  objective  lens  must  reach  and  be  made  to  approach 
the  object  as  nearly  as  possible  within  good  focus.  It  is  therefore  best 
to  carry  the  eye-piece  toward  the  opposite  side  of  the  body  luitil  the 
shaft  of  the  instrument  is  nearly  parallel  with  the  thigh  and  then  by 
raising  the  eye-piece  and  withdrawing  or  advancing  the  instrument 
bring  the  ureter  of  the  opposite  side  into  view.  After  this,  its  fellow  is 
studied  in  the  same  way. 

Changes  in  the  meatus  do  not  occur,  as  a  rule,  through  prostatic 
enlargement  imless  ureteritis,  pyelitis  or  pyonephrosis  has  occurred. 
Obstruction  of  the  ureter  is  still  more  rare  unless  cancer  of  the  prostate 
is  prcseiit.  In  questions  of  doubt  the  ureteral  catheter  settles  the  matter. 

The  trigonum  as  a  whole  is  then  studied  by  field-zones  ISO  degrees 


HYPERTROPHY  OF  THE  PROSTATE  947 

in  extent  by  the  plan  of  withdrawing  the  instrument  detailed  in  pre- 
ceding pages. 

In  the  same  manner  the  remaining  three  segments — subperitoneal, 
urachal  and  retropubic — are  explored  as  carefully  as  the  general  and 
vesical  condition  will  permit. 

Inflammation  of  the  bladder  may  be  acute  but  more  usually  is 
chronic  or  an  exacerbation  of  chronic  disease.  The  acute  inflam- 
mation shows  various  degrees  of  localized  or  generalized  congestion 
and  hyperemia  proportional  with  the  severity  of  the  subjective  symp- 
toms. The  chronic  inflammation  reveals  pallor,  absence  of  vessels, 
edema,  infiltration,  inelasticity,  mucus,  pus  and  perhaps  blood,  in 
stringy,  flaky  or  fluid  form,  scaling  of  the  epithelium  or  of  phosphatic 
deposits  and  stone — all  in  various  association  and  relation. 

The  sequels  of  inflammation  are  practically  accentuation  and  exten- 
sion of  these  conditions. 

Trabeculations  of  the  Bladder. — Hypertrophy  of  the  prostate  may 
have  congenital  or  acquired  trabeculations.  The  congenital  forms  are 
seen  in  the  early  cases  before  obstruction  and  cystitis  begin,  are  purely 
anatomical  peculiarities,  may  disappear  under  increased  distention  with 
fluid,  are  very  superf  cial  and  without  sacculations  in  their  midst  or 
diseased  mucous  membrane  over  their  surfaces  because  cystitis  has  not 
yet  occurred.  Pathological  trabeculations  accompany  other  signs  of 
obstruction,  are  due  to  hypertrophy  of  muscular  bundles  in  overcoming 
the  strain,  do  not  change  under  increasing  distention,  are  prominent 
and  surrounded  with  sacculations  of  various  depths,  the  mucous  mem- 
brane is  in  a  state  of  intractable  chronic  cystitis  owing  to  the  retention. 
Plugs  of  mucus  and  pus,  also  flakes  and  concretions  of  phosphatic  pre- 
cipitate, often  are  seen  within  the  sacculations. 

Diverticula  of  the  Bladder. — Hypertrophy  of  the  prostate  is  some- 
times associated  with  diverticula  as  anatomical  defects  and  not  as 
acquired  lesions  through  the  disease  of  the  gland.  They  are,  therefore, 
strictly  congenital  and  have  all  the  characteristics  assigned  to  them  In 
the  section  on  the  Diseased  Bladder  in  Cystoscopy.  They  are  usually 
situated  in  the  subperitoneal  and  urachal  segments  of  the  bladder 
which  are  relatively  unsupported  when  compared  with  the  uretero- 
trlgonal  and  the  retropubic  segments  which  are  respectively  held  more 
or  less  firm  by  the  prostate  and  pubic  symphysis,  against  pressure 
from  within. 

Sacculations  of  the  bladder  are  probably  for  similar  reasons  more 
common  in  the  subperitoneal  and  urachal  segments  than  elsewhere. 
They  are  never  seen  excepting  In  association  with  prominent  trabecu- 
lations and  more  or  less  cystitis.  They  are  always  acquired  from 
obstruction,  through  strain  and  from  Inflammation. 

Retroprostatic  Pouch. — In  hypertrophy  of  the  prostate  this  depres- 
sion occupies  the  subperitoneal  segments  almost  entirely  and  lies 
behind  the  ureteric  and  Interureterlc  folds.  In  the  normal  bladder  this 
segment  recedes  at  a  slight  angle  below  the  level  of  the  trigonum.  As 
the  prostate  enlarges  upward  this  declivity  mcreases  and  as  the  ob- 


94S  DISEASES  OF  THE  PROSTATE 

stnu'tion  of  the  ])r()state  advances  tlio  iiouchiiisi;  process  begins  behind 
this  line  where  the  strain  is  probably  greatest  to  evacuate  the  bladder 
over  tlie  gland.  This  pouch  is  the  seat  of  the  residual  urine  witli  its 
precipitation  of  salts,  chronic  cystitis,  sacculations  and  often  diverti- 
cula. The  retrojn-ostatic  j^ouch  is  the  chief  deformity  of  the  bladder 
hi  ])rostatic  obstruction  and  the  chief  seat  of  the  secondary  diseases 
of  the  bladtler  in  this  condition.  It  should  be  carefully  studied  luider 
the  limit  of  distention  tolerated  by  the  patient. 

Prominence  of  the  Prostate. — TIyj)ertro])hy  in  cystoscopy  is  noted  as  a 
whole  for  size,  form  generalized  or  lobular  iiivolvemcjit,  obstruction  of 
tlie  urethra,  deformation  of  the  bladder  and  lobulations  with  their 
relation  to  the  urethra  and  ureters.  In  order  to  carry  out  this  study  the 
cystoscopist  must  be  very  familiar  with  his  instrument,  es])ecially  with 
the  erect  or  nnerted  image  they  ])roduce  whose  ])oles  but  not  sides  are 
reversed.  The  amount  of  magnifications  should  be  known  as  well  as 
comparison  between  the  pictures  of  the  near  and  remote  image  instru- 
ments. The  retrovision  telescope  should  always  be  used  in  confirma- 
tion of  the  findings.  The  Buerger  cNstourethroscoj^e  is  of  great  A'alue 
for  study  of  the  neck  of  the  bladder  and  the  prostatic  urethra,  when  it 
may  be  introduced  and  manipulated. 

Charting  of  the  Hypertrophy. — Cystoscopy  charts  have  been  suggested 
by  Young  with  the  following  general  details:  The  cyst()sco})e  is  with- 
drawn until  the  field  is  invaded  by  the  gland  for  about  half  its  extent, 
especially  when  the  neck  of  the  bladder  is  being  mspected.  The 
cystoscope  is  now  rotated  through  o()()  degrees,  beginning,  by  preference 
in  the  writer's  opinion,  with  the  middle  of  the  interureteric  bar.  Thus 
is  revealed  the  prostate  as  a  whole  and  the  general  location  and  features 
of  any  lobidar  enlargement  are  noted  for  description  diu'ing  the  serial 
inspection,  especially  if  either  ureter  is  affected. 

Young's  chart  for  mapping  the  prostate  consists  of  eight  circles  of 
the  diameter  of  the  cystoscopic  field  arranged  in  a  circle  and  of  sixteen 
similar  circles  in  a  square  outside  these.  The  author's  method  of 
systemic  examination  of  the  bladder,  segment  by  segment,  field-zone 
by  field-zone,  as  described  on  p.  949,  is  essential  for  good  results. 
Each  segment  is  studied  by  withdrawing  or  inserting  and  then  rotating 
the  cystoscope  to  4.^  degrees  which  will  cover  as  much  of  the  bladder 
as  one  of  Young's  eight  circles.  The  insertion  or  withdrawal  of  the 
instrument  reveals  the  anteroposterior  features  and  the  rotation  the 
side  to  side  features. 

The  eight  circles  will  give  the  general  outli]ie  of  the  ])rostatic  con- 
dition while  the  features  of  a  single  lobe  may  l^e  graphically  detailed  hi 
the  circles  of  the  square  corresponding  with  the  central  circle  or  circle 
which  the  lobular  deformity  appears  as  a  whole. 

At  the  center  of  the  chart  after  the  outlines  have  been  inserted  within 
the  circles,  a  cross-section  drawing  of  the  posterior  urethra  may  be 
placed  after  Young's  method.  In  these  cross-section  diagrams  it  should 
be  remembered  that  all  convexities  denote  protrusions,  all  concavities 
mean  depressions  by  prominence  opposite  them  and  all  sulci  occur 
between  two  protrusions  or  protrusion  and  a  concavity. 


HYPERTROPHY  OF  THE  PROSTATE 


949 


In  this  accurate  work  the  habit  of  bef^iniiiii^  always  at  one  point 
such  as  the  middle  of  the  iiiterureteric  })ar  should  be  be^un  and  main- 
tained. 

Bilateral  <^enerali/ed  liy])ertro])hy  of  tlie  prostate  is  showji  perfectly 
by  Young's  chart.  It  will  l)e  noted  that  deep  sulci  are  in  the  up])er  and 
lower  polar  fields  and  that  all  the  other  fields  are  greatly  encroached 
by  the  gland.  Therefore,  in  the  center  of  the  diagram  a  vertical  slit 
represents  the  cross-section  of  the  neck  of  the  })ladder  and  posterior 
urethra. 


Fig.  346. — Young's  chart  of  prostatic  cystoscopic  fields.  The  inner  circle  of  eight 
fields  gives  the  general  survey  of  the  prostate  and  neck  of  the  bladder.  The  outer  square 
of  sixteen  circles  affords  two  extra  ^dews  instead  of  one  in  quadrant,  between  the  poles 
and  the  equator. 

Marked  median  lobe  hypertrophy  of  the  prostate  (at  the  expense  of 
the  roof)  is  also  well  charted.  The  lower  polar  field  is  nearly  covered 
wath  the  enlargement  and  the  fields  at  either  side  of  this  show  the  sulci 
between  the  median  and  the  lateral  lobes  which  are  practically  without 
much  change.  In  the  center  of  the  diagram,  therefore,  a  crescent  with 
the  convexity  upward  is  the  cross-section  of  the  urethra. 

Median  hypertrophy  of  the  prostate  (at  the  expense  of  the  floor)  is 


950  DISEASES  OF  THE  PROSTATE 

« 

rare  but  does  occur  with  all  the  features  of  the  forejroing  diajxram 
reversed.  A  crescent  with  the  comexity  downward  therefore  i)resents 
tlie  cross-section  of  the  urethra. 

Bilateral  and  median  hy])ertrophy  of  the  ])r(>state  is  alst)  fully  out- 
lined. It  will  he  noted  that  the  ui)])er  polar  circle  shows  the  dee]>  sulcus 
between  the  two  lateral  lobes,  the  lower  polar  circle  is  nearly  covered 
with  the  prominence  of  the  median  lobe  and  the  circles  adjacent  thereto 
contain  the  sulci  between  this  and  the  lateral  lobes.  The  arrangement 
within  the  urethra  is  ])racticall\'  three  convexities  about  a  connnon 
center. 

This  representation  changes  if  one  lateral  lobe  has  escaped  or  if  less 
enlarged  on  the  principle  that  the  convexity  points  toward  the  direc- 
tion of  growth  and  procee^ls  from  the  growing  lobe.  Thus  diagrams 
might  easily  be  showji  of  m(>dian  with  right  lateral  and  of  median  with 
left  lateral  iuNolvement. 

Bilateral  and  confluent  median  hypertrophy  gives  a  distinct  dia- 
gram. It  is  noted  that  the  upper  polar  circle  alone  contains  a  sidciis, 
that  bet\Aeen  the  two  lateral  lobes,  while  the  confluence  bet^^een  the 
median  and  the  lateral  lobes  ^^ipes  out  the  sulci  on  each  side  of  the 
lower  polar  circle.  Cross-section  of  the  urethra  is  therefore  revealed 
as  a  deep,  vertical  slit  leading  from  a  contractured  orifice. 

Contracture  of  the  neck  of  the  bladder  (\\ithout  i)r()static  hyper- 
troi)hy  but  with  prostatic  symptoms)  will  give  a  tliagram  showing 
encroachment  of  each  field  without  sulci.  Its  cross-sectioii  would  be  a 
small,  more  or  less  regular  circle. 

The  normal  prostate  gives  a  uniform  picture  n\  ith  a  slight  convexity 
at  the  lower  ])ole  where  the  gland  protrudes  slightly  ijito  the  bladder. 

Cautions  in  Cystoscopy. — In  hypertrophy  of  the  prostate  the  dangers 
of  instrumentation  rest  on  the  presence  of  complicating  sequels,  such  as 
nephritis,  pyelitis,  pyelonephritis  and  pyonephrosis.  Serious  reflex 
effects  on  the  kidneys  may  follow  a  cystoscopy  in  these  comi)licated 
cases  which  are  usually  so  advanced  as  to  be  beyond  surgical  aid, 
especially  in  the  presence  of  advanced  years.  Fenwick^  lays  down  the 
principle  that  a  man  of  over  forty-five  years  of  age,  presenting  the 
nocturnal  incontinence  of  prostatism  and  the  great  thirst  of  ne]:)hritis 
contra  indicates  cystoscopic  investigations. 

The  prostate  of  such  a  patient  may  very  well  be  outlined  by  a  careful 
bimanual  examination  \\ith  considerable  pressure  upward  of  the  rectal 
finger  in  order  to  bring  the  gland  into  closer  reach  of  the  abdominal 
hand. 

Prostatics  may  be  cystoscoped  in  this  ])erio(l  of  our  knowledge  when 
formerly  they  would  not  be  so  investigated.  No  force  must  be  used,  if 
possible  no  traumatism  produced,  and  the  investigation  should  be 
postponed  until  kno\\"ledge  of  the  caliber,  tortuosity  and  length  of  the 
urethra  is  fixed.  In  general  a  narrow,  tortuous  prostatic  urethra  in 
these  cases,  when  combined  with  the  complications  and  sequels  of 

'  Clinical  Cystoscopy,  1904,  pp.  525  and  526. 


TTYPERTROPTIY  OF  THE  PROHrArE  951 

damaged  kidneys,  is  the  chief  element  of  danger.  Many  of  the  ordinary 
risks  of  cystoscopy  in  hypertrophy  of  the  prostate  are  rem<Ae(l  by 
lavage  of  the  bladder  before  and  after  the  instrumentation  with  silver 
nitrate  solution,  from  1  to  5000  to  1  to  1000,  and  by-  the  preliminary 
and  subsequent  administration  of  urinary  ajitiseptics  internally.  Acute 
and  subacute  symptoms  of  cystitis  should  be  relieved  as  a  preliminary, 
while  rest  in  bed  both  before  and  after,  and  the  judiciously  copious 
drinking  of  water  as  a  stimulant  of  the  kidneys  after  instrumentation 
are  very  essential  details  of  precaution  and  care. 

Diagnosis.— The  application  of  the  .r-ray  to  the  recognition  of  hyper- 
trophy of  the  prostate  is  comparatively  recent  in  this  country.  Evans^ 
says  that  in  English  the  only  important  contribution  is  that  of  Ilyman 
and  Jaches.2  Evans  shows  an  ;r-ray  photograph  of  a  case  of  his  own, 
seen  in  Fig.  347  and  says:  "The  anteroposterior  plate  was  negative  for 
shadows,  either  of  a  calculus  or  any  other  shadow  of  pathological 
importance.  The  postero-anterior  plate  (see  cut)  shows  a  pear-shaped 
shadow,  which  was  diagnosed  as  an  enlarged  prostate.  The  findings 
were  verified  by  operation."  Evans  concludes  that  the  best  skiagram 
of  the  prostate  is  obtained  with  the  patient  lying  on  his  belly. 


Fig.  347. — -Posteroanterior  plate  of  the  bladder.     The  small  round  shadow  to  the  right 
is  a  phlebolith.     (Evans.) 

Hyman  and  Jaches  in  the  foregoing  article  simplified  the  older  pro- 
cedure of  oxygen  inflation  by  means  of  the  complicated  apparatus  of 
Burkliardt  and  Floerchen.  The  method  is  of  ^•alue  when  cystoscopy  is 
impossible. 

Treatment. — ^Like  diagnosis,  treatment  must  be  abbreviated  because 
these  paragraphs  deal  chiefly  with  cystoscopy.  The  abortive  meas- 
ures are  impossible  in  the  nature  of  the  chronic  productive  process 

1  Am.  Jour,  of  Roent.,  April,   1917,  p.   196. 

2  Surg.,  Gynec.  and  Obst.,  vol.  xix,  p.  409. 


952  DISEASES  OF  THE  PROSTATE 

and  propliylaxis  is  devoted  to  the  possible  complications,  chiefly 
cystitis,  ureteritis  and  nephritis  throufjh  the  administration  of  urinary 
antiseptics,  attention  to  the  action  of  the  bowels  and  skin  and  through 
vesical  irriiration  with  antiseptics.  Palliatii)n  really  extends  ]M"oj)liy- 
laxis  in  the  proper  api)lication  of  catheter  life,  which  is  now  nearly 
obsolete  through  the  advantages  of  early  diagnosis  of  prostatism,  the 
recognition  of  com])lications  and  sequels  and  the  ])roper  selection  of 
case  for  operation  and  the  method  of  procedure.  All  these  factors  add 
to  the  safety  of  the  operation. 

The  curative  measures  are  only  surgical.  Foretreatment  is  all- 
important  to  prepare  the  patient  and  the  urinary  system  for  the  oper- 
ation. Among  the  older  operations  is  the  Bottini,  which  cauterizes  the 
neck  of  the  bladder  without  perineal  drainage.  It  has  served  its  day 
and  is  now  rarely  used,  having  been  supplanted  by  Chetwood's' 
perineal  galvanoprostatotomy  which  adds  perineal  section  and  drainage 
to  cauterization.  This  operation  is  also  nearly  obsolete  and  is  useful 
chiefly  in  contracture  of  the  neck  of  the  bladder  without  prostatism. 
Prostatectomy  by  the  suprapubic  route  of  Fuller"  in  this  country  and  of 
Freyer*  in  England,  or  by  the  perineal  route  of  Young*  in  this  comitry  is 
the  o])eration  of  choice.  The  two-stage  suprapubic  prostatectomy  has 
been  further  (le\el()ped  by  Pilcher^  more  than  any  one  else  in  the  I  nited 
States.  The  details  of  these  operations  are  omitted  in  the  nature  of 
these  chapters  on  cystoscopy. 

Braa^ch  Excisor. — An  improvement  on  the  Chetwood  and  Young 
methods  is  that  of  Braasch.^  "The  instrument  consists  of  three 
separate  sheaths  of  decreasing  caliber  which  are  so  arranged  that  the 
smaller  sheath  fits  into  the  next  larger.  The  outside  sheath  {A)  is 
practically  a  urethroscope.  The  light  is  situated  at  the  distal  end  in  the 
beak,  and  it  has  an  irrigating  cock  near  the  proximal  end.  The  window 
is  of  plain  glass  without  magnification  and  fits  all  three  sheaths.  The 
observer  looks  through  the  tul)e  filled  with  water,  after  the  principle 
employed  in  my  irrigating  cystoscope.''  xAfter  the  obstructing  tissue  is 
brought  into  view,  the  second  sheath  {B)  is  introduced.  This  has  a 
collar  at  its  distal  end  which  is  armed  with  two  irregular  teeth  by  means 
of  which  the  tissue  is  held  in  place.  The  latter  procedure  is  also  ujider 
the  guidance  of  direct  vision.  Then  the  inner  or  knife  sheath  {C)  is 
introduced  and  the  tissue  cut  while  still  in  view.  The  blood  from  the 
woiuid  is  usually  washed  from  the  field  by  the  rapidly  entering  irrigating 
fluid.  The  advantages  of  this  instrument  are  obvious.  Without  a 
visualized  field,  unless  the  operator  is  very  expert,  it  is  evident  that  the 
base  of  the  bladder  instead  of  the  median  bar  might  easily  be  cut." 

Aftertreatment — The  wound,  the  bladder  and  the  urethra  all  require 
attention.  As  a  rule,  the  woimd  is  healed  in  from  three  to  eight  weeks, 

'  Am.  Assn.  of  Gen.-Urin  Surgeons,  1901,  and  Med.  Rec,  1901. 

*  Jour.  Cutan.  and  Gen.-Urin.  Diseases,  June,  1895. 

3  British  Med.  Jour.,  1901,  ii,  125.  ■*  Jour.  Am.  Med.  Assn.,  1903,  xli,  999. 

'  Surg.,  Gynec.  and  Obst.,  February,  1917,  xxiv,  163. 

•  Jour.  Am.  Med.  Assn.,  vol.  Ixx,  No.  11,  p.  758. 
'  Am.  Jonc.  Urol.,  1912,  viii,  115-119. 


TIYPERTROPJJY  OF  THE  PROHTATE 


953 


often  with  one  or  several  nilapses  of  the  sums  and  finally  witfi  total 
closure.  The  wound  is  allowed  to  heal  by  granulation  on  general 
surgical  principles,  being  kept  clean  by  frequent  changes  of  dressings 


Fig.  348. — Median  bar  excisor.     (Braasch.) 

and  various  forms  of  drainage.  Morton^  employs  a  single  16  C.P. 
incandescent  electric  lamp  under  an  ordinary  fracture  frame  covered 
with  bed  clothing  and  sufficiently  near  the  wound  to  give  gentle  heat. 

'  At  a  personal  demonstration  to  the  author  at  his  cHnic  at  the  Long  Island  College 
Hospital,  May,  1917. 


954 


DISEASES  OF  THE  PROSTATE 


Thv  period  of  ai>i)lication  of  an  hour  or  two  is  followed  by  one  of  rest. 
The  wound  is  not  covered  with  any  dressing  and  is  foimd  by  ]\lorton 
to  be  stimulated  greatly  by  this  simple  procedure.  Hemorrhage  after 
prostatectoMi>-  is  often  very  troublesome.  Among  the  means  of  arrest- 
hig  bleeding  one  of  the  best  is  the  bag  of  Pileher.'  Like  all  similar 
devices  it  has  its  limitationsandcautionsljut  is  undoubtedly  serviceable. 


Fig.  349. — -Urethral  and  suprapubic  vesical  drains.  M  is  the  Malecot  catheter;  P 
is  the  Pesser  catheter  and  M.L.  is  the  Malecot- Lebretou  catheter  whose  shaft  is  woven 
silk  and  eye  soft  rubber.  F  is  the  Freyer  suprapubic  drain  with  glass  elbow  and  F.I.  is 
irrigating  pattern  of  the  Freyer  tube,  whose  small  inlet  should  be  shortened  to  the  length 
of  the  large  segment. 


Fig.  350. — Pasteau  olivc-ixunicil,  tinRlr  iIImiw,  double  eye,  cj-lindrical  catheter;  A  with 
35  degrees  and  B  with  45  degrees  angle  of  tip. 


The  device  is  a  simple  inflatable  rubber  bag,  fashioned  about  a  large 
size  catheter. 

The  open  tube  catheter  is  entered  first  through  the  suprapubic 
wound,  over  a  silver  catheter,  and  drawn  down  through  the  urethra. 

1  Surg.,  Gynec.  and  Obst.,  February,  1917. 


HYPERTROPHY  OF  THE  PROSTATE 


955 


When  the  bag  is  in  the  })lad(ler  with  the  ti)})e  in  the;  urethra,  the  }>ajr  is 
inflated  through  the  inflating  tube,  and  the  inflated  bag  is  used  for 
pressure  against  the  bleeding  surface  from  which  the  prostate  was 
removed. 


Fig.  354 

Figs.  351-354. — Elbow  woven  silk  catheters.  Round  tip,  single  elbow,  double  eye  model; 
showing  from  above  downward  the  40,  35,  30  and  25  degrees  angle  of  the  elbow. 

When  pressure  is  desired,  the  catheter  attachment  is  pulled  upon, 
which  brings  the  bag  more  tightly  into  contact  with  the  bleeding  surface. 
This  pressure  may  be  maintained  by  attaching  the  catheter  tube  to  the 
leg.  The  catheter  tube  also  acts  as  an  avenue  for  the  escape  of  the 
urine  from  the  bladder. 


Fig.  355  is  the  double  elbow,  double  eye  form.     The  shafts  of  these  instruments  are 
cylindrical,  oval  from  side  to  side  and  oval  from  top  to  bottom  according  to  choice. 

By  this  means  a  safe  and  positive  hemorrhage  control  is  provided 
which  may  be  removed  within  an  hour,  if  desired,  and  reapplied  at 
will,  without  disturbing  the  patient.  Its  removal  at  the  same  time 
that  the  drainage  tube  is  changed  is  accomplished  with  relatively  little 
discomfort  to  the  patient. 


956 


DISEASES  OF  THE  PROSTATE 


CHRONIC  PROSTATITIS. 

Varieties. — ("hroiiic  ])r()statitis  is  cataiTlial,  in  which  intVctioiis  ])us 
is  nioiv  or  less  absent  but  re])hi{'e(l  by  imicopus,  and  sup])UTati^■e,  in 
which  the  reverse  condition  t)btains  with  tlie  added  tendency  to  sei)tic 
SNinptonis.  Chronic  suppurative  prostatitis  is  sometimes  accom- 
panied by  lithiasis  of  the  i)rostate.  To  the  cystoscoi^ist  both  forms 
present  about  the  same  condition. 

Cystoscopy. — In  chronic  i)rostatitis  tlie  cystoscoi)e  re^■eals  a  rather 
dilHcult  insertion  of  the  instrument  usually  through  ijifiltration  and 
rigidity  of  the  canal  through  the  same  conditions  of  the  gland  which 
encroaches  on  the  prostatic  urethra  as  a  whole.  The  bladder  as  a  whole 
is  normal  except  where  in  direct  contact  with  the  diseased  ])rostate. 
The  trigonum  is  hy])eremic,  swollen,  edematous,  infiltrated  and  promi- 
nent. The  neck  of  tlie  bladder  is  thickened,  indurated  and  may  show 
the  "prostatic  bar." 

Ci/,'it<)iir('thn)sc()})i/. — When  the  instrument  may  be  ])assed  in  chronic 
prostatitis  it  verifies  all  the  foregoing  findings  as  a,  close  vision  instru- 
ment, and  adds  the  minute  study  of  the  neck  of  the  bladder  and  pros- 
tatic urethra  which  frequently  shows  edema,  hyperemia,  cystic  degener- 
ation and  enlarged  follicles  from  which  pus  may  often  be  seen  extruding 
into  the  field  or  by  rectal  pressure  may  be  squeezed  out. 


Fig.  356. — Median  lobe  of  prostate.     (Aiithor'.s  ease.) 


Author's  Seven-glass  Test. — In  chrcmic  prostatitis  this  multiple  glass 
test  is  a  valuable  aid  in  diagnosis.  The  anterior  urethral  and  control 
glasses  will  be  clear,  the  posterior  urethral  glass  turbid  and  contain 
characteristic  prostatic  elements,  the  bladder  glass  will  be  clear,  and 
the  massage  glass  loaded  with  prostatic  elements.  If  cystitis  is  present 
also,  as  in  some  cases,  the  bladder  glass  will  also  be  turbid  but  free 
of  prostatic  elements,  containing  only  bladder  detritus. 

Another  advantage  is  the  distincticm  of  the  vesicles  from  the  prostate 


NEOPLASM  OF  TIfK  I' HOST  ATE  957 

and  from  each  other  in  the  contents  of  (I hisses  V,  VI  and  VTT,  respec- 
tively, taken  from  the  prostate  aiid  each  seminal  sac.  The  (J(!tails  of 
this  test  are  described  on  page  455. 

Median  lobular  hypertrophy  of  the  prostate;  difl'ers  from  chronic 
prostatitis  in  cystoscopy  in  that  the  lob(!  may  overlif;  but  does  not 
usually  change  the  trigonmn .  The  prostatic  urethra  is  changed  in  much 
less  degree  so  that  the  entering  instrument  encounters  there  no  obstruc- 
tion, but  only  in  the  bladder  as  it  passes  to  either  side  or  over  the 
median  lobe. 

TUBERCULOUS  PROSTATITIS. 

Cystoscopy. — In  tuberculous  prostatitis  cystoscopic  investigation 
has  an  element  of  risk  of  infecting  the  bladder  which  may  previously 
have  escaped.  Tuberculous  prostatitis  without  vesical  symptoms  is 
often  regarded  as  a  contraindication  to  cystoscopy,  but  the  preliminary 
administration  of  urinary  antiseptics  and  the  subsequent  lavage  of  the 
bladder  are  usually  sufficient  to  meet  this  danger. 

Tuberculous  prostatitis  with  vesical  symptoms  is,  on  the  other  hand, 
a  direct  indication  for  cystoscopy,  and  reveals  absence  of  true  hyper- 
trophy of  the  gland,  either  lobular  or  generalized,  but  irregular  enlarge- 
ment covered  with  granular,  hyperemic  mucosa  with  hemorrhagic 
tendencies  and  occasional  ulcers  and  tubercles. 

Cystourethroscoyy . — When  the  insertion  of  the  cystourethroscope  is 
possible,  display  the  tuberculous  conditions  in  the  urethra,  in  many 
cases  as  shown  in  Fig.  214.  Tubercles  may  be  found  and  the  discharge 
of  pus  from  the  follicles  and  ducts  observed  or  induced  by  rectal  touch. 

The  bladder  as  a  whole  usually  escapes  any  findings  for  the  cysto- 
scope  excepting  the  conditions  described  overlying  the  prostate  itself. 
Severe  lesions  belong  to  advanced  cases. 

Caution  of  Cystoscopy. — Tuberculous  prostatitis  requires  irrigation 
of  the  bladder  and  the  urethra  with  antiseptics  of  mild  type  as  the 
final  step,  as  suggested  in  the  discussion  of  tuberculous  cystitis. 

Rectal  Examination. — The  tuberculous  prostate  shows  a  gland  whose 
surface  is  granular  and  nodular  and  whose  enlargement  is  without 
order.  Sensitive  soft  spots  are  found  and  the  Wolbarst  five-glass  test 
is  abundant  in  pus  in  the  prostatic  urethral  glass  and  in  the  massage 
glass,  in  which  tubercle  bacilli  may  commonly  be  discovered  by  bac- 
teriology and  animal  experimentation. 

NEOPLASM  OF  THE  PROSTATE. 

Varieties. — Neoplasm  of  the  prostate  in  cystoscopy  includes  only 
carcinoma  and  sarcoma.  Carcinoma  alone  is  important  as  sarcoma  is 
very  rare,  even  in  old  age,  although  in  childhood  it  is  practically  the 
only  neoplasm  of  the  prostate. 

Cystoscopy  in  Carcinoma. — The  cystoscope  in  canCer  of  the  prostate  is 
far  from  satisfactory  as  a  means  of  diagnosis  because  the  interior  of  the 
bladder  is  changed  late  in  this  disease.    Rectal  touch  is  of  more  value  in 


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X 
Fig.  357. — Autopsy  spccinioii.    Bladder 
opened.       Ulceration     around     internal 
urethral  orifice  (.Y). 


Fir..  358. — Autojjsy  specimen,  show- 
infi  extensive  involvement  of  the  pros- 
tate.    X,  urethral  orifice. 


'-y."^ 


.■'v.<--:f 


Fig.  359. — Roll's  case,  showing  tubercle 
with  giant-cells  and  caseation;  also  pros- 
tatic tubule  with  amj-hjid  body. 


Fig.  3G0. — Koll's  case,  showing  forma- 
tion, caseation  and  some  normal  prostatic 

tubules. 


'       .  ?i '  ■  «:'■  ■■■■  :i;:;«** 


Fig.  361. — KoU's  case,  showing  high  degree  of  infiltration. 
Figs.  357-361. — Primary  tuberculosis  of  the  prostate  gland.     (KoUO- 

>  Ann.  Surg.,  vol.  xxxvii,  No.  5;  Tr.  Am.  Urol.  Assn.,  1915,  ix,  365. 


NEOPLASM  OF  THE  FROST  A  TE  959 

reaching  the  deposits  of  the  growth  at  the  posterior  commissure  of  the 
gland  where  it  commonly  begins.  From  this  point  it  invades  the 
glandular  substance  per  se,  after  which  operation  becomes  of  little  value. 
When  the  gland  has  become  invaded  more  or  less  deformity  of  the  blad- 
der floor  with  residual  urine,  cystitis  and  many  other  symjjtoms  of 
senile  hypertrophy  of  the  prostate  may  supervene. 

The  discovery  of  a  very  hard,  stony  gland  in  part  or  in  whole  through 
the  rectum  and  of  the  conditions  within  the  blood  suggesting  carcinoma, 
are  more  reliable  for  diagnosis  than  cystoscopy. 

Carcinoma  starts  in  the  posterior  commissure  of  the  prostate  and  has 
a  definite  tendency  to  early  fixation  of  the  gland,  hence,  when  this 
fixation  is  present  as  distinguished  from  the  mobility  of  even  large 
hypertrophies,  the  diagnosis  of  malignancy  may  be  regarded  as  definite. 

Radium  Treatment  of  Cancer  of  the  Prostate. — This  subject  has  offered 
little  encouragement  until  Barringer^  developed  the  plan  of  loading  a 
needle  with  radium  and  carrying  the  same  into  the  substance  of  the 
glands;  his  technic  is  described  in  the  foregoing  article  in  the  following 
terms : 

"  Technic  of  Application  of  Radium. — Because  the  carcinoma  starts  in 
the  interior  of  the  prostate  gland,  and  radium  by  urethra  or  rectum 
often  causes  intense  irritation,  I  have  applied  the  radium  differently. 
A  needle  41  inches  long  and  about  18  gauge  has  been  used.  From  .50  to 
100  millicuries  of  radium  have  been  placed  in  the  end  of  this  needle  for 
a  distance  varying  between  f  inch  to  1|  inches  according  to  the  indi- 
cations of  the  individual  case.  The  patient  is  placed  in  a  lithotomy 
position,  a  finger  introduced  into  the  rectum  and  the  perineum  between 
the  urethra  and  rectum  is  anesthetized  with  novocain  (1  per  cent.).  I 
have  frequently  inserted  the  needle  without  anesthetization,  causing 
very  little  pain.  The  radium  needle  is  than  plunged  into  the  perineum 
between  the  urethra  and  rectum,  and,  guided  by  the  rectal  finger,  the 
end  of  the  needle  is  passed  into  the  middle  of  one  or  the  other  of  the 
carcinomatous  lobes.^  After  the  needle  is  introduced,  the  patient 
frequently  does  not  feel  its  presence.  The  needle  is  left  in  place  from 
four  to  six  hours.  If  one  wishes  to  irradiate  the  other  lobe,  the  needle 
is  pulled  out  of  the  first  lobe  and  introduced  into  the  second  and  left 
there  the  proper  time.  The  ease  of  this  procedure  is  obvious.  I  was 
nearly  dissuaded  from  using  this  method  by  reports  of  necrosis  follow- 
ing the  use  of  unscreened  radium.  I  have  now  used  the  needles  in  the 
prostate  fifteen  times,  and  to  date  have  had  no  radium  sloughs.  These 
patients  are  apt  to  have  burning  and  pain  beginning  the  week  after  the 
radium  is  used  and  lasting  for  from  one  to  two  weeks.  During  this  time 
the  prostate  swells,  and  the  maximum  effect  of  the  radium  on  the 
growth  is  not  to  be  looked  for  until  two  or  tlu-ee  months.  Some  patients, 
notably  those  with  the  carcinoma  extending  into  the  vesicles,  have  a 
great  deal  of  pain.    Neither  the  pain,  however,  nor  the  urinary  dis- 

1  Loc.  cit. 

^  The  needle  in  the  prostate  also  serves  to  exclude  prostatic  stone,  the  one  condition 
hard  to  differentiate  from  carcinoma. 


960  DISEASES  OF  THE  PROSTATE 

turbance  is  as  fjreat  as  when  the  radium  is  used  in  the  bladder.  And 
curiously  enough,  radium  in  the  urethra  seems  to  cause  or  increase  an 
already  present  residual  urine;  while  this  needle  method,  as  far  as  I 
have  observed,  does  not.  There  is  a  certain  class  of  borderland  cases  in 
which  the  carcinoma  has  broken  through  into  the  bladder  neck  and  in 
which  it  is  a  question  whether  to  use  the  prostate  needles  or  the  screened 
radium  in  the  bladder  neck.  1  think  these  cases  should  be  started  with 
prostate  needles,  as  the  reaction  is  often  little  or  nothing." 

Differential  Diagnosis. — Prostatic  disease  involves  chiefly  its  distinc- 
tion from  \ arious  \esical  lesions,  because  the  early  subjective  sxiidrome 
of  prostatic  involvement  is  vesical  and  only  in  later  as  the  disease 
advances  are  the  uretlira,  ureters  and  kidneys  included.  The  most 
imj^ortant  vesical  conditions  for  consideration  are  vesical  calculus, 
neoplasm  ])aralysis,  and  contracture  of  the  neck  of  the  bladder. 

Vesical  calculus  difiers  from  prostatic  disease  in  the  findings  by  the 
cystoscope,  the  stone  searcher  and  rectal  and  bimanual  examination. 
There  is  no  enlargement  of  the  gland  except  by  congestion.  Cystitis 
is  commonly  an  earlier  and  more  marked  lesion  and  sometimes  the  con- 
cretion may  be  percei^'ed  between  the  hands  in  a  bimanual  examination. 
The  subjecti\'e  symptoms  are  those  of  congestion  and  irritation  of  the 
bladder  floor  and  prostate  with  nocturnal  and  diurnal  pollakiuria  so 
as  to  make  distinction  from  early  prostatic  hypertrophy  most  difficult. 
In  ad\'anced  life  vesical  lithiasis  may  precede  prostatic  change  with 
little  cystitis  or  at  most  one  of  low  grade,  with  very  slow  development 
of  the  stone. 

In  true  h^-pertrophy  of  the  prostate  stone  is  often  present  and  not 
suspected  or  found  until  o{)eration,  or  even  at  that  time  overlooked 
unless  care  be  taken  to  feel  for  stones  before  the  envcleation.  The  stone 
is  usually  free  in  the  retroprostatic  pouch  or  more  or  less  fixed  in  a 
sacculation  secondary  to  chronic  cystitis,  or  in  an  anatomical  diverti- 
culum. With  the  cystoscope  in  place  and  the  stone  in  view,  its  mobility 
and  freedom  from  such  attachments  may  be  demonstrated  by  lifting 
the  prostate  or  bladder  with  the  finger  in  the  rectum.  Stone  as  a  sequel 
of  prostatic  enlargement  and  cystitis  occurs  in  about  one-fourth  of  all 
patients. 

J^esical  neojAasm  differs  from  hypertrophy  of  the  prostate  chiefly  m  the 
cystoscopic  demonstration.  This  is  easy  if  the  base  of  the  tumor  may 
be  studied  and  shown  to  be  embedded  in  normal  mucous  membrane. 
The  direct-vision  and  close-vision  instruments  are  very  serviceable  for 
this  point.  Implantation  of  the  tumor  at  any  part  of  the  bladder  except 
the  trigonum  over  the  prostate  in  particular  is  a  distinguishing  element. 

Benign  papilloma  of  the  bladder  has  its  own  characteristics,  as 
previously  described  in  this  subject. 

Ulcerating  papillary  carcinoma  with  its  sessile  base,  earlier  cystitis 
and  frequent  attachment  around  the  trigonum  is  far  more  difficult  of 
diagnosis  unless  the  mucous  membrane  is  still  normal  and  may  be 
followed  up  into  the  base  of  the  neoplasm. 

Infiltrating  carcinoma,  if  in  the  trigonum,  cannot  be  distinguished 
from  prostatic  conditions. 


CONTRACTURE  OF  TIIIC  NECK  OF  THE  liLADDEIi  (iOl 

Paralysis  or  ^paresis  of  the  bladder  wall  dijfers  from  hyperlrojjhy  of  the 
prostate  in  havinf^  a  negative  rectal  and  V)irnanual  examination  and  at 
least,  in  the  early  cases,  of  always  showing  a  cystoscopic  pictnrf;  of 
normal  mucosa  throughout  the  bladder  cavity  and  of  a  prostate  without 
general  or  median  lobe  involvement.  The  reason  for  the  symj)toms  of 
prostatism  are  that  the  weakness  or  paralysis  of  the  })ladder  muscle 
prevents  total  and  permits  only  partial  evacuation  of  its  contents.  If 
the  residual  urine  is  large  in  quantity,  and  a  cause  of  cystitis  exists  and 
this  lesion  supervenes,  then  the  picture  of  prostatic  disease  is  almost 
typical.  The  commonest  source  of  such  a  bladder  is  tabes  dorsalis 
and,  of  course,  is  of  syphilitic  origin.  The  presence  of  the  physical 
signs  and  symptoms  of  tabes  preceding  and  accompanying  such 
bladder  symptoms  is  usually  the  diagnostic  point. 

CONTRACTURE  OF  THE  NECK  OF  THE  BLADDER. 

Synonym. — Prostatism  without  enlargement  of  the  prostate  is  the 
other  term  usually  applied  to  this  condition  whose  clinical  signs  so 
closely  simulate  those  of  true  hypertrophy  of  the  prostate  that  it  must 
always  be  considered  when  other  signs  of  hypertrophy  are  lacking  and 
when  a  history  of  chronic  inflammation  is  given.  Chetwood^  has 
studied  this  condition  very  thoroughly  and  points  out  that  Guthrie,^ 
1836,  Mercier,^  1856,  Sokell,^  1874,  Civiale,^  Von  Frisch,«  1899,  and 
Sir  Henry  Thompson''  have  all  more  or  less  deHberately  and  definitely 
described  it. 

Etiology. — Contracture  of  the  neck  of  the  bladder  is  usually  inde- 
pendent of  but  may  be  identified  with  true  hypertrophy  of  the  prostate 
and  complicate  the  picture  thereof.  The  essential  factor  is  chronic, 
deeply  seated,  suppurative  inflammation  followed  by  chronic  produc- 
tive inflammation  on  either  the  vesical  or  the  urethral  surface  of  the 
neck  of  the  bladder  or  both. 

Pathology. — Contracture  of  the  neck  of  the  bladder  varies  with  the 
presence  or  absence  of  prostatic  hypertrophy. 

If  the  prostate  itself  is  normal,  the  pathology  is  that  of  chronic 
suppuration  and  infiltration  with  secondary  fibrous  contracture.  The 
overlying  mucosa  in  either  or  both  bladder  or  urethra  is  thickened 
and  polypoid,  the  muscle  body  is  invaded  by  the  sclerosing  process, 
the  vesical  outlet  is  deformed,  elevated,  displaced  and  more  or  less  or 
sometimes  totally  closed.  In  short,  the  condition  is  that  of  stricture  of 
the  urethra  located  in  or  about  the  outlet  of  the  bladder  and  its  muscle, 

1  The  Practice  of  Urology,  1913,  p.  435. 

2  London,  1836;  Lectures,  vol.  xvi,  p.  271. 

3  R^cherches  Anatomiques,  Pathologique  et  Therapeutiques  sur  les  Maladies  des 
Organes  Urinaires,  Genitaires,  etc.,  Paris,  1841,  ix,  p.  372,  also  Recherches  sur  le  Traite- 
ment  des  Maladies  des  Organes  G6nito-urinaries,  1856. 

^  Th^se  de  Paris,  1874. 

^  Traite  Practique  sur  les  Maladies  des  Organes  Genito-Urinaires,  Paris,  1841,  II,  v, 
241-256. 

^  Krankheiten  der  Prostata,  ii,  1910. 

'  Diseases  of  the  Prostate,  Prize  Essay,  1856,  xvii,  p.  293. 
61 


962  DISEASES  OF  THE  PROSTATE 

If  tnio  hypei-tvoi)hy  of  tlie  prostate  is  coexistent  all  its  characteristic 
progressing  pathological  signs  are  added  to  those  of  tlie  contracture  at 
the  vesical  neck. 

Subjective  and  Objective  Syndromes. — The  subjective  s\n"i])toms  are 
practically  identical  with  those  of  stricture  of  the  urethra  or  of  early 
prostatic  hypcrtroi)hy,  nocturnal  and  diurnal  frcciuency  of  urination, 
occasional  uivoluntary  emptying  of  the  bladder,  dysuria,  hesitation  in 
starting,  decrease  in  the  size  and  force  of  the  stream  primarily  due  to 
the  obstruction  and  s(>condaril>-  dnc  to  the  atony  of  overstrained 
muscle. 

()bjecti^•e  symptoms  of  contracture  of  the  neck  of  the  bladder  vary 
with  the  absence  or  presence  of  hypertrophy  of  the  prostate. 

If  the  prostate  is  not  enlarged  the  urethra  is  free  of  obstruction  uj) 
to  and  usually  throngh  the  si)hincter,  a  blunt  point  sound  being  momen- 
tarily arrested,  then  suddeidy  jumping  over  the  constriction.  A  short- 
beak  stone  searcher  passes  in  the  same  manner  and  when  reversed  with 
its  beak  backward,  catches  at  a  distinctly  narrow  ridge  on  being  with- 
drawn.   The  urethral  length  is  unchanged. 

"With  ])rostatic  hy])ertro])hy  present  all  the  characteristic  symptoms 
and  signs  of  this  condition  are  added  to  those  of  the  constriction  at  the 
neck  of  the  bladder. 

Cystoscopy. — I'^rinalysis  shows  a  normal  bladder  except  in  late  cases 
with  secondary  cystitis.  In  contracture  of  the  neck  of  the  bladder 
cystoscopy  is  best  performed  with  close-vision  instruments,  such  as  the 
Acmi  or  ( 'hetwood  convex  sheath  types,  or  better,  with  the  Buerger 
cystourethroscope  as  this  permits  exammation  of  the  urethra  at  the 
same  sitting. 

The  muscle  is  found  to  present  a  prominent,  fixed,  irregular,  inelastic, 
congested  or  pale,  elevated  margin.  Within  the  bladder  around  the 
sphincter  and  within  the  prostatic  urethra  distal  to  it,  the  mucosa  is  in 
a  state  of  chronic  congestion  or  inflammation,  or  more  or  less  pale 
from  the  sclerosing  process,  much  as  is  seen  in  stricture  of  the  urethra 
at  other  points. 

Diagnosis. — The  diagnosis  of  contracture  of  the  neck  of  the  bladder 
rests  on  the  absence  of  tabes  dorsalis  or  other  form  of  spinal  paralysis 
and  stricture  of  the  urethra  as  the  other  common  causes  of  retention  of 
the  urine,  and  on  the  presence  of  a  urethra  with  normal  caliber  and 
length  and  a  prostate  without  hypertrophy. 

The  contracture  itself  must  be  instrumentally  determined.  The 
common  soimd  with  blunt  point  will  usually  enter  easily  after  a  brief 
hesitation  followed  l^y  a  slip  over  the  i)uckered  muscle.  The  short 
stone-searcher  of  Thompson  recognizes  the  same  condition  and  proves 
it  by  hooking  upon  it  if  withdrawn  with  its  beak  turned  l)ackward  into 
the  middle  line.  Palpation  with  the  stone-searcher  of  the  bladder  floor 
eliminates  intravesical  hypertrophy  of  the  prostate. 

Cystoscopy  confirms  these  findings  by  adding  a  normal  bladder  as  a 
whole  and  no  prostatic  change. 

Operation  adds  the  final  step  in  diagnosis.    The  normal  outlet  of  the 


LITTTIASrS  OF  THE  rUOSTATE  963 

bladder  is  to  the  operatiji^  fiiiK^'r  firm  and  elastic;  })ut  when  eontracture 
of  the  neck  exists  a  hard,  inelastic  bar  is  felt  which  is  passed  with 
difficulty  at  best,  or  with  tearing  if  force  is  used,  or  may  even  be 
impassable. 

Contracture  of  the  neck  of  the  bladder  should  therefore  Ix'  tlioii{i;lit 
of  in  any  subject  showing  the  symptoms  of  prostatism  with  an 
unchanged  gland. 

Dangers. — That  the  Young  prostatic  punch  may  result  in  s(;rious 
accident  if  its  teeth  are  bent  outward  is  shown  by  the  re[)ort  of  Swin- 
burne,^ "after  the  insertion  of  the  instrument  while  it  was  in  the  bladder, 
and  then  withdrawing  it,  instead  of  catching  the  bar  it  slipped  into  the 
urethral  canal  and  caught  about  four  inches  from  the  meatus.  I 
noticed,  on  inserting  the  instrument,  that  it  was  rather  tight  at  that 
point.  I  could  not  move  the  instrument  either  way.  I  attem})ted  to 
shut  the  knife  down  and  perhaps  cut  off  that  bite.  It  did  not  do  any- 
thing. There  was  nothing  to  do  but  perform  an  external  urethrotomy. 
When  I  got  the  instrument  out  I  found  that  one  of  the  teeth  had  been 
turned  a  little  bit  outward." 

LITHIASIS  OF  THE  PROSTATE. 

Occurrence. — Stone  in  the  prostate  is  rare  but  its  significance  is  great. 
Multiple  small  stones  are  the  rule,  as  shown  in  the  author's  specimen. 
Fig.  362. 

Varieties. — Primary  cases  are  practically  unknown,  as  all  have  ante- 
cedent infections.  The  disease  is  never  acute  but  may  have  severe 
symptoms  by  recent  or  relapsed  infection.  It  is  essentially  chronic 
like  lithiasis  elsewhere. 

Etiology.^As  in  all  other  lithiasis  the  exact  cause  is  unkno-s\ii  but  the 
factors  are  probably  a  gland  damaged  by  old  disease  or  changed  by 
hypertrophy  with  infection  precipitating  the  chemical  elements  of  the 
normal  fluid. 

Pathology. — The  stones  occur  by  precipitation  in  the  acini  of  the  gland 
and  usually  in  one  lobe  or  part  of  a  lobe  rather  than  in  the  gland  as 
a  whole.  There  are  no  temporary  lesions  except  the  accompanying 
infection  which  may  recover  after  the  stones  are  removed,  leaving 
behind  them,  however,  changes  in  the  gland  similar  to  those  seen  in 
the  kidney,  for  example,  by  the  formation  pressure  and  attrition.  The 
associated  conditions  are  the  cystitis  and  other  ascending  infection  and 
the  chronic  posterior  urethritis  seen  with  other  prostatic  conditions. 

Symptoms. — To  those  of  prostatic  hypertrophy  are  added  the  results 
of  the  stones :  Pain,  bleeding,  discharge,  pollakiuria,  tenesmus  and  the 
passing  of  stones.  The  pain  is  usually  deep  seated,  permeal,  increased 
by  urination,  defecation  and  attempted  coitus.  It  is  most  marked  when 
a  stone  is  being  passed,  and  is  then  urethra.  The  bleeding  is  often  only 
microscopic  but  may  be  copious,  especially  after  straining  at  stool  or 

1  Tr.  Am.  Urol.  Assn.,  1915,  Lx,  289. 


964 


DISEASES  OF  THE  P  HOST  ATE 


other  trauma.  The  diseluiry;e  is  urethral,  moderate  or  marked  aud 
usually'  iufeeted  witli  Narious ortjauisuis.  The ])()nakiuria  and  teuesnuis 
rest  on  the  physieal  ami  rellex  irritation  of  the  stones  aud  the  accompany- 
ing cystitis.  The  passing  of  stones  is  variable.  The  author's  spechnen, 
out  of  more  than  a  hundred,  iuun])ers  well  over  thirty  stones  almost 
l^ainlessly  ])assed  by  au  old  uian. 


Fig.  .362. — Prostatic  (-ilculi.  \'oluiitarily  voidod,  often  impacting  in  the  urethra, 
making  them  temporarily  urethral  calculi;  weight  7.36  grammes;  composition  urethrostie 
and  urate  salts;  occurrence  in  a  sailor,  aged  eighty  years,  in  robust  health  other  than 
enlarged  prostate  with  cystitis;  specimen  one-fourth  of  whole  quantity  passed.  (Author's 
case.') 


The  objective  symptoms  are  those  of  the  enlarged  prostate  with  hard 
discrete  nodules  or  crepitating  masses,  positive  urethroscopic  and 
cystoscopic  e.xaminaticm,  .r-ray  verification  and  occasionally  impact  on 
sounds  for  other  exploring  instruments.  Impacted  stones  are  occasion- 
ally ])alpated  or  urethr()se()])ed.  Discharge  may  be  studied  as  in  ure- 
thritis and  the  dysuria  and  tenesmus  noted. 

The  termination  of  these  cases  is  advaiicuig  sup])uration,  compli- 
cating infections,  and  destruction  of  part  or  all  the  gland  in  neglected 
cases.    Treatment  may  restore  reasonable  local  and  bodily  health. 

Diagnosis. — The  history,  subjective  symptoms,  objective  symptoms, 
urethroscopy,  cystoscopy  and  roe]itgeiu)logy  settle  the  (juestion.  Some 
stones  are  silent  and  discovered  at  operation. 

Treatment. — As  soon  as  the  diagnosis  is  made  the  stones  should  be 
remo\'ed  by  prostatotomy  in  mild  cases,  occasional  during  sexual  life 
or  by  prostatectomy  in  se^'ere  cases  in  age. 

•  Loc.  cit. 


INDEX. 


Abscess,  gonococcal  metastatic,  235 
diagnosis  of,  236 
etiology  of,  236 
occurrence  of,  235 
significance  of,  235 
symptoms  of,  236 
treatment  of,  236 
perinephritic,    differentiation    from 

pyonephrosis,  186 
periurethral  acute,  101 

definition  of,  101 
diagnosis  of,  102 
etiology  of,  101 
pathology  of,  101 
symptoms  of,  102 
varieties  of,  101 
chronic,  102,  311 

follicular,  102 
foUicular,  101 

aftertreatment  of,  104 
electrotherapy  of,  103 
hydi'otherapy  of,  103 
serotherapy  of,  203 
surgical  management  of,  104 
treatment  of,  103 

instrumental,  104 
prostatic,  117 

BaciUus  coli  in  pus  of,  117 
treatment  of,  125 
of  seminal  vesicles,  130 
subphrenic,    differentiation    from 

pyonephrosis,  186 
of  uterus,  intramural  gonococcal,  610 
Acquired  stricture  of  urethra,  338 
Age  as  factor  in  gonococcal  infection,  614 
Alcohol  in  gonorrhea,  496 
Alkaline   combinations  for  neutrahzing 

urine,  57 
Amorphous  urinary  sediment,  46 
Anaphylaxis,  476 
Anemia  of  bladder,  756 
Anesthetics  in  cystoscopy,  729 

in  urethroscopy,  628 
Aneurysmal    hemorrhage   from    kidney, 

936 
Angioma,  renal.     See  Varix,  renal. 
Antiblennorrhagics  in  acute  urethritis, 
503 
in  chl-om'c  urethritis,  504 
Antibodies,  475 

Antipyrin  in  treatment  of  chordee,  58 
Anus,  chancroid  of,  215 


Anus,  funnel  shaped,  sodomy  and,  211 
Aortitis,  gonococcal,  225   . 
Appendages,   uterine,   gonococcal  infec- 
tion of,  577.     See  Uterine  appendages, 
gonococcal  infection  of. 
Appendicitis,  diagnosis  of,  587 
Ardor  urina;  in  urethritis,  40 
Arthralgia,  gonococcal,  252 
Arthritis,  gonococcal,  248 
diagnosis  of,  255 
etiology-  of,  249 
pathology  of,  251 
sjTuptoms  of,  254 
treatment  of,  257 
varieties  of,  249 
Artificial  pol}airia,   847.     See  PohTiria, 
artificial, 
temporary    glycosuria,    849.     See 
Gl3'cosuria,  artificial  temporary. 
Asjmdromic    hemorrhage   from    kidney, 
929 


B 


Bacillus  coU  as  cause  of  ureteritis,  177 
commimis  in  acute  urethritis, 
20;  22,  44 
in  prostatic  abscess,  117 
in  urine,  471 
diphtheriae,  acute  urethritis  and,  22 
of  Ducrey,  20,  22 
tuberculosis,  urethritis  and,  22 

in  m'ine,  472 
tj^hosus  in  acute  urethritis,  22 
Bacteremia,  gonococcal,  225 
definition  of,  225 
diagnosis  of,  229 
etiologv  of,  227 
pathology  of,  228 
significance  of,  225 
sjonptoms  of,  228 
treatment  of,  230 
Bacterial  casts  in  urine,  466 
chrom"c  urethritis,  264 
nongonococcal  acute  urethritis,  22 
Bacteriemia.     See  Bacteremia. 
Bacterin,  combined,  of  Van  Cott,  514 

gonococcal,  513 
Balanitis,  89 

acute,  treatment  of,  96 
cancerous,  diagnosis  of,  96 
cardiovascular,  diagnosis  of,  98 
chanci'oidal,  92 

diagnosis  of,  95 


966 


INDEX 


Balanitis,  chronic,  90,  308 
dotinition  of,  308 
diagnosis  of,  310 
pathology  of,  309 
symptoms  of,  309 
.    treatment  of.  96,  310 
varieties  of,  309 
croupous,  iliagnosis  of,  94 
definition  of,  89 
dial>etie,  92 

iliagnosis  of,  95 
diagnt)sis  of,  93 

difTerential,  94 
diphtheritic,  diagnosis  of,  94 
etiology  of,  90 
gonococcal  acute,  91 

diagnosis  of,  94-95 
treatment  of,  96 
microorganisms  as  causes  of,  90 
pai)illomatous,  diagnosis  of,  9t) 
pathology  of,  90 
relapsing,  308 
sujiinn-ative,  94 
syniiJtoms  of,  91 
sj-pliilitic,  92 

diagnosis  of,  94 
varieties,  89 

with  irretractible  foreskin,  92 
with  retractihle  foreskin,  91 
Balanoposthitis,  89 

acute,  treatment  of,  96 

chronic,     96,    308.     See    Balanitis, 

chronic, 
diagnosis  of,  laboratory,  445 
gonococcal  acute.    See  Balanitis, 
relapsing,  308 
Ballenger's  method  of  aborting  gonor- 
rhea, 49,  491 
Bangs'  syringe-sound,  295 
Bilharziasis,  804 

of  kidney,  937 
Bladder,  al)normaUties     of,     cystoscopy 
of,  810 
affections  of,  753 

varieties  of,  754 
anemia  of,  756 
calculi  of,  cystoscopy  of,  808 
cancer  of,  775 
fungoid,  776 
indurated,  776 
infiltrating,  780 
papillary,  779 
superficial,  776 
cavity  of,  changes  in  size  and  shape 

of,  752 
cystoscopy    of,    during    operations, 
811 
preparation  for,  735 
diseased,  753 
distomiasis  of,  803 
echinococcus  of,  803 
edema  of,  758  ^ 

fibroma  of,  778 
foreign  bodies  in,  799 

treatment  of,  808 
hyperemia  of,  active,  757 


Biadiler,  hyperemia  of,  passive,  758 
irrigation  of,  368,  371 
one-journey,  371 
two-journey,  368,  374 
ischemia  of,  75ti 
lesions  of,  754 
leukoplakia  of,  802 
Uthiasis  of,  790 

cystoscopy  of,  792 
diagnosis  of,  796 
etiology  of,  795 
management  of,  797 
treatment  of.  797 
varieties  of,  795 
management  of,  in  cystoscopy,  736 
mucosa  of,  cystoscopic  subdivisions 
of,  749 
edema  of,  759 

huUosum,  759 
hytlatidiforme,  759 
inspection  of,  748 
serous  etTusion  of,  758 
simple  cysts  of,  760 
muscularis  of,  lesions  of,  760 

reactions  of,  760 
m5'oma  of,  778 
neck  of,  749 

contracture  of,  961 
cystoscopy  of,  962 
diagnosis  of,  962 
etiology  of,  961 
pathology  of,  961 
sj'ndromes  of,  962 
objective,  962 
subjective,  962 
synonyms  of,  961 
urethroscopy  of,  640,  647 
neoplasms  of,  776 
diagnosis  of,  777 

cj'stoscopic,  781 
differentiation   of,    cystoscopic, 

783 
transitional,  781 
treatment  of,  784 
cystoscopic,  810 
Hagner's  method  of,  784 
Squier's  method  of,  785 
with  radiimi,  789 
varieties  of,  778 
normal,  740 

anatomy  of,  740 
orientation  of,  742 

with    axial    vision    cystoscope, 

746 
with  cystovu'ethroscope,  747 
with  lateral  vision  cystoscope, 
744 
papilloma  of,  778 
parasitic  diseases  of,  803 
plans  of  examination  of,  742 
purpura  of,  801 
rare  affections  of,  801 

anatomical,  801  ^ 
circulatory,  801 
inflammatory,  802 
traumatic,  806 


INDEX 


967 


Bladder,  sarcoma  of,  781 
simple  ulcer  of,  807 
therapeutics  of,  cystoscopic,  806 
trigone  or  trigonum  of,  749 

simple  edema  of,  259 
tuberculosis  of,  808 
ulceration  of,  773 
cancerous,  775 
definition  of,  773 
solitary,  of  Fenwick,  774 
traumatic,  773 
typhoid,  774 
varieties  of,  773 
ureteral  orifices  of,  750  * 
Blood  casts  in  urine,  466 
cholesterin  in,  865 
corpuscles  in  urine,  459 
creatinine  in,  865 
cryoscopy  of,  846 
gonococcus  in,  complement  fixation 

test  for,  479 
noncoagulable  protein  in,  865 
salts  in,  866 
sugar  in,  866 
urea  in,  863 
uric  acid  in,  864 
Bougie-a-boule.     See  Bougies,  bulbous. 
Bougies,  bulbous,  in  urethral  stricture, 

347 
Braasch  excisor,  952 
Brick  dust  urinary  sediment,  467 
Bromides  in  treatment  of  chordee,  58 
Bulb  of  urethra,  anatomy  of,  435 
Bulbous  edema  of  posterior  urethra,  652 
Bursitis,  gonococcal,  248 
treatment  of,  257 


Cabot's  colorimetric  tubes,  857 
Calcium  oxalate,  467 
CalcuU  of  bladder,  cystoscopy  of,  808 
renal.     See  Kidney,  lithiasis  of. 
of  ureter,  836 

chemical  composition  of,  837 
cystoscopy  of,  838 
diagnosis  of,  837 
impacted,  836 
migratory,  836 
sequels  of,  837 
treatment  of,  839 
ureteral  catheterization  in,  839 
of  urethra,  urethroscopy  of,  675 
in  females,  680 
Calculous  spermatocystitis,  diagnosis  of, 

132 
Cancerous  balanitis,  diagnosis  of,  96 
Carcinoma  of  bladder,  775 
fungoid,  776 
indurated,  776 
infiltrating,  780 
papillary,  779 
'superficial,  776 
of  urethra,  urethroscopy  of,  672 
in  female,  671 


(Jardiac  lesions,  gonococcal,  223 
pathology  of,  224 
syrnpioms  f)f,  224 
ircatrnorit  of,  224 
Cardiovascular  balanitis,  diagnosis  of,  96 
system,  complications  of,  in  urethri- 
tis, 223 
Caruncle,  urethral,  268 
Casper's  phlfjridzin  test,  850 
Casts  in  urine,  463 

bacterial,  466 
blood,  466 
crystalline,  466 
definition  of,  463 
false,  466 
fatty,  466 
granular,  465 
hyaline,  464 
pus,  466 
waxy,  465 
Catarrhal  acute  pyelitis,  868 
definition  of,  868 
diagnosis  of,  869 
differentiation  of,  869 
etiology  of,  868 
pathogenesis  of,  868 
of  pregnancy,  870 
syndrome  of,  869 
treatment  of,  870 
urethritis,  bacteriology  of,  22 
diagnosis  of,  43 

urethroscopic,  661 
etiology  of,  20 
pathology  of,  28 
sjTuptoms  of,  36 
treatment  of,  urethroscopic, 
661 
Catheter,  indwelling,  in  spermatocystitis, 
137  _ 
irrigation    treatment    of   urethritis, 

64,  69,  79 
ureteral,  advancement  of,  824 
degree  of  penetration  of,  824 
duration  of  retention  of,  825 
molding  of  retained,  826 
Catheterization  in  prostatitis,  125 
Celluhtis,  pelvic,  diagnosis  of,  587 
Cerebri  tis.     See  Encephahtis. 
Cervicitis,  gonococcal,  547 

aftertreatment  of,  555 
chronic,  549 
cure  of,  556 
diagnosis  of,  551 

differential,  551 
hydi'otherapy  of,  553 
medication  in,  553 
pathology  of,  547 
relapsing,  550 
significance  of,  547 
surgery  of,  555 
symptoms  of,  548 
treatment  of,  552 
varieties  of,  547 
neoplastic,  552 
sypliihtic,  551 
tuberculous,  552 


96S 


INDEX 


Cervix,  ;un]nitati()n  of.  573 

afti'itn-atinont  of,  573 
cure  of,  573 
mode  of  getting  specimens  from,  482 
Chancre  of  iiretliia,  304 
Chancroid  of  anus,  215 
of  rectum,  "215 
of  urethra,  20.  30,  304 
Chancroidal  acute  urethritis,   diagnosis 
of,  45 
etiology  of,  20 
balanitis,  92 

diagnosis  of,  95 
chronic  urethritis.  304 

treatment  of,  304 
urethritis.  urethrosc()])y  of,  G()4 
Chancrous  chronic  luvthritis,  304 
Chetwood     doul)le-current     method    in 

urethritis,  72.  SO 
Children,  prophylactic  treatment  of  after 

coitus,  480 
Cholesterin  in  blood,  865 
Chondritis,  gonococcal,  248 
treatment  of,  257 
Chordce,  35,  40 

prevention  of,  58 
treatment  of,  58 
Choroiditis     (chorioiditis),     gonococcal, 

240 
Circumcision  in  treatment  of  phimosis, 

87 
Cocci,  Gram-negative,  26 
Coitus,  precautions  after,  485,  486 
Colic,  spermatic,  128 
Colon,  neoplasm  of,  pyonephrosis  and, 

differentiation  of,  187 
Colorimeter,  Cabot's  colorimetric  tubes, 
857 
of  Duboscq,  855 
Dunning's,  858 
HelUge  modified,  856 
universal,  856 
Complement  fixation  test,  476 

in  diagnosis  of  gonorrhea, 

33,  39 
for  gonococcus,  478 
laboratory  technic  of,  478 
hmitations  of,  478 
preparation   of  blood  for, 
477 
Composite  cystoscope,  704 
Condom  in  prophylaxis  of  gonorrhea,  485 
Condylomata  acuminata,  202 
aftertreatment  of,  207 
in  anus,  211 
definition  of,  202 
diagnosis  of,  204 

differential,  204 
electrotherapy  of,  206 
etiology  of,  203 
gonococcal,  in  female,  599 
diagnosis  of,  602  ' 
etiology  of,  600  ! 

surgery  of,  603 
symptoms  of,  600 
treatment  of,  602  i 


Condj'lomata  acuminata,  local  measures 
in,  207 
pathology  of,  203 
surgery  of,  207 
symptoms  of,  204 
synonyms  of,  202 
treatment  of,  205 
lata,  204 
syphilitic,  204 
Congenital  stricture  of  urethra,  338 
Conjunctivitis,  gonococcal,  241 
congenital,  241 

pathology  of,  242 
symptoms  of,  242 
diagnosis  of,  244 
dilTerentialion  of,  245 
etiology  of,  241 
hydrotherapy  of,  246 
medication  in,  246 
occurrence  of,  241 
significance  of,  241 
surgery  of,  247 
termination  of,  244 
treatment  of,  246 
nongonococcal,  242 
purulent,  bacteriology  of,  245 
diagnosis  of,  245 
Contracture  of  neck  of  bladder,  961 
cystoscojjy  of,  962 
diagnosis  of,  962 
etiology  of,  961 
pathology  of,  961 
sj'ndromes  of,  962 
synonyms  of,  961 
Copaiba  in  treatment  of  urethritis,  67 
Cowperitis,  109 

acute,  with  retention,  112 

without  retention,  112 
aftertreatment  of,  115 
chronic,  112,  312 

diagnosis  of,  312 
occurrence  of,  312 
pathology  of,  312 
significance  of,  312 
symptoms  of,  312 
treatment  of,  312 
varieties  of,  312 
with  retention,  312 
without  retention,  312 
diagnosis  of,  112 
electrotherapy  of,  113 
gonococcal  acute,  109-115 
treatment  of,  1 12 
curative,  113 
pathology  of.  111 
surgical  management  of,  114 
symptoms  of,  111 
varieties  of,  109 
with  retention,  HI 
Cowper's  glands,  anatomy  of,  435 

examination-technic  of,  435 
pathology  of,  435 
Creatinine  in  blood,  865 
Croupous  balanitis,  diagnosis  of,  94 
Cryoscopy,  846 

advantages  of,  846 


INDEX 


969 


Cryoscopy,  apparatus  for,  846 
of  blood,  846 
disadvantages  of,  846 
principles  of,  846 
sources  of  error  in,  847  • 

technic  of,  847 
of  urine,  846 
Crystals,  urinary,  466 

ammonium  urate,  467 

calcium  oxalate,  467 

triple  phosphates,  468 

uric  acid,  467 
Cubebs  in  treatment  of  urethritis,  67 
Cutaneous  lesions  in  urethritis,  201 
Cystitis,  166,  761 
acute,  762 

distribution  of,  762 

extension  of,  762 
aftertreatment  of,  176 

constitutional,  177 
chronic,  328,  766 

diagnosis  of,  171,  329 

distribution  of,  764 

pathology  of,  328 

special  forms  of,  764 

symptoms  of,  328 

treatment  of,  329 
compUcations  of,  169 
cure  of,  evidences  of,  177 
definition  of,  166,  761 
diagnosis  of,  169 

differentiation  from  posterior  ure- 
thritis, 172 

from  pyelitis,  172 

from  pyelonephritis,  172 

from  pyonephrosis,  172 
disseminate,  807 
electrotherapy  of,  174 
etiology  of,  166 
follicular,  766 

following  treatment  of  stricture,  416 
diagnosis  of,  417 
etiology  of,  417 
treatment  of,  418 
from  urethral  obstruction,  764 
glandularis,  766 
gonococcal,  766 

acute,  766 

treatment  of,  173 

chronic,  766 

treatment  of,  173 

diagnosis  of,  171 

in  female,  598 
granulans,  766 
hemorrhagic,  765 
Knorr's,  766 

local  management  of,  174 
medication  in,  174 
membranous,  765 
nongonococcal,  diagnosis  of,  171 
operations  for,  175 
pathology  of,  167 
phototherapy  of,  174 
senilis  feminarum,  772 
serotherapy  of,  174 
seven-glass  test  in  diagnosis  of,  168 


Cystitis,  subacute,  763 

sui)rai)ubic  cystotomy  in,  176 
surgery  of,  175 
syrnjjtoms  of,  167 

sul>j(^ctive,  762 
t(!rniiriation  of,  169 
tuberculous,  767 

cystoscopic  pictures  of,  769 

definition  of,  767 

differential  diagnosis  of,  770 

focal  symptoms  of,  767 

pathology  of,  768 

urinalysis  of,  768 
turbidity  t(;sts  of,  170 
urethrotomy  in,  176 
varieties  of,  166,  761 
Cystoscope,  702 

accessories  to,  704 
axial  vision,  in  ureteral  catheteriza- 
tion, 828 
Braasch's,  833 
for  catheterization,  703 
composite,  704 
development  of.  702 
Eisner's,  833 
for  examination,  703 
introduction  of,  740 
laterovision  in  ureteral  catheteriza- 
tion, 830 
for  operation,  703 
optical  principles  of,  703 
retention  of,  in  ureteral  catheteriza- 
tion, 829 
tubular,  704 
types  of,  702 
universal,  704 
Cystoscopy,  682 

of  abnormalities  of  bladder,  810 

anesthetics  in,  729 

assistant  for,  725 

basic  principles  of,  682 

of  bladder,  during  operations,  Sll 

of  calculi  of  bladder,  808 

of  ureter,  838 
case  histories  in,  686 

records  in,  694 
cautions  concerning,  694 
of  chronic  prostatitis,  956 
of  contractxire  of  neck  of  bladder, 

962 
contraindications  of,  694 
diagnosis  charts  in,  701 
difficulties  in,  resume  of,  739 
electrical  generator  for,  715 
equipment  for,  711 
fever  as  indication  for,  693 
general  confirmations  of,  683 

indications  for,  682,  688 

treatment  chart  in,  701 
history  of,  702 
in  home,  725 
in  hospitals,  723 
in  hydronephrosis,  898 
in  h}-pertrophy  of  prostate,  943 
indications  for.  688 
instrximent  table  for,  724 


970 


INDEX 


Cystoscopy,   irrigating   attachments  of, 
713 
leggings  for,  721 
in  litliiasis  of  bladder,  792 

of  kidney.  DIS 
lubricants  used  in,  719 
management  of  l)ladder  in,  736 
of  neoplasni  of  bladder,  810 
nurse's  duties  in,  725 
pain  as  indication  for,  ()93 
poor  visibility  in,  737 
postiu'es  for,  723,  727 
preliminaries  of,  733 
preparation  for,  720 

of  patient,  720 

of  room,  720 
prercciuisites  for,  732 
in  i)rofessional  office,  722 

floor  i)lan  for,  722 
sexual  investigation  in,  686 
sources  of  error  in,  754 
sterilization  of  apparatus  for,  717 
storage  of  apparatus  for,  715 
in  surgical  cases,  69-1 
tables  for,  723 
technic  of,  726 

in  ureteral  catheterization,  829 
urethral  investigation  in,  686,  691 
urinalysis  in,  690 

charts  in,  700 
urination  cards  in,  700 
of  wounds  of  ureter,  840 
Cystotomv,  suprajiubic,  in  cystitis,  176 
Cysts  of  bladder,  760 
of  kidney,  937 
of  prostate,  utricular,  urethroscopy 

of,  666 
of  urethra,  follicular,  urethroscopy 
of,  667 


D'Arsoxval  liigh-frequency  current,  501 
Diabetic  balanitis,  92 

diagnosis  of,  95 
Diagnosis,  elements  of,  428 
general  principles  of,  428 
history  blank  for,  429 
physical  examination  in  432 
general,  432 
local,  433 
rectal,  434 
Diathermy,  501 

indications  for,  502 
Diathetic  urethritis,  302 
acute,  302 

pathology  of,  28 
anterior,  302 
chronic,  302 
posterior,  302 

treatment  of,  302  ^ 

Diet  in  gonorrhea,  496 
Digestion,  disturbances  of,  in  urethritis, 

207 
Dilatation  in  chronic  urethritis,  287 
gradual,  institution  of,  375 


Dilatation,  gratlual,  for  stricture,  365 
indications  for,  in  stricture,  366 
sounds  for,  370 

Beni(iue,  370,  371 
•       grooved,  370,  372 
irrigating,  370,  372 
tunneleil,  370,  372 
urethral,    with    metal    instruments, 
i>77 
with  soft  instruments,  377 
vs.  operation  for  stricture,  363 
Dilators,  selection  of,  375 
Diphtlierilie  lialaiiitis,  diagnosis  of,  94 
Diplococeus  gonorrha?a>,  24 
Disciiarge  in  gonorrhea,  41 
Distoma  lu'matol)ia,  S04 
Distomiasis  o{  bladder,  803 
Dressings  in  gonorrhea,  497 
Drinks  in  gonorrhea,  496 
Duboscq,  colorimeter  of,  855 
Ducrey's  bacillus,  20,  22,^30,  43,  46 
Dimning's  colorimeter,  858 


E 


EcHiNOCOCCUS  of  bladder,  803 

of  kidney,  939 
Edema  of  bladder,  758,  759 

bulbous,  of  jiosterior  urethra,  652 
of  scrotum  in  eindidymitis,  151 
Edematous  stricture  of  urethra,  341,  349 
Electrodes,  prostatic,  502 

urethral,  502 
Electrolysis  of  stricture,  384 
Electrotherapy  of  cowperitis,  113 
of  gonococcal  folliculitis,  101 
of  gonorrhea,  499 
of  i)eriurethral  abscess,  103 
of  prostatitis,  123 
rectal,  in  urethritis,  293 
of  spermatocystitis,  135 
EncephaUtis,  gonococcal,  239 
Endocarditis,  gonococcal,  224 
Endometritis,  gonococcal,  556 
acute,  559 

aftertreatment  of,  565 
chronic,  558,  559 

curettage  in,  565 
hydrotherapy  of,  563 
medication  in,  563 
surgery  of,  564 
treatment  of,  563 
cure  of,  565 
diagnosis  of,  501 

differential,  561 
etiology  of,  956 
hydrotherapy  of,  562 
hysterectomy  in,  573 

aftertreatment  of,  576 
cure  of,  576 
subtotal,  575 
total,  574 
medication  in,  563 
pathology  of,  557 
prophylaxis  of,  562 


INDEX 


971 


Endometritis,  gonococcal,  significance  of, 
556 

varieties  of,  556 
Epididymitis,  146 

acute,  in  undescended  testis,  153 
cessation  of  discharge  in,  151 
chronic,  152,  324 

diagnosis  of,  327 

etiology  of,  324 

occurrence  of,  324 

pathology  of,  326 

symptoms  of,  326 

treatment  of,  327 

tuberculosis  and,  157 

varieties  of,  324 
classification  of,  147 
clinical  importance  of,  146 
cure  of,  evidence  of,  162 
diagnosis  of,  153 
electrotherapy  of,  159 
epididymotomy  in,  160 
epididymo vasostomy  in,  161 
etiology  of,  147 

following  treatment  of  stricture,  416 
diagnosis  of,  417 
etiology  of,  416 
treatment  of,  418 
funiculitis  in,  153 
gonococcal,  146 

acute,  differential  diagnosis  of, 
153 

association    with    spermato- 
cystitis,  149 
hydrotherapy  of,  159 
neoplastic,  156 

nongonococcal,  etiology  of,  148 
pathology  of,  148 
prognosis  of,  152 
prophylaxis  of,  157 
recurrent,  152 
relapsing  acute,  152 

chronic,  152 
rubber  bandage  in  treatment  of,  159 
sequelae  of,  152 
serotherapy  of,  159 
sterihty  following,  152 
strapping  of  testis  in,  160 
subacute,  152 
sjonptoms  of,  149 

local,  150 

systemic,  150 
syphilitic,  156 
termination  of,  151 
treatment  of,  157 

curative,  159 

operative,  160 
tuberculous,  155,  157 
urethritis  in,  treatment  of,  160 
Epididymoorchitis.     See  Epididymitis. 
Epididymotomy,  160 
Epididymovasostomy  in  epididymitis,  161 
Epithelia  in  urine,  461 

mensuration  of,  463 

renal,  462 
ureteral,  462 

urethral,  462 


EpitheHa  in  urine,  vesical,  462 
J']ruptivo  acute  urethritis,  28 
Erysipelas,  scrotal,  diagnosis  of,  153 
Extravasation  of  urine,  424.    See  Urine, 
extravasation  of. 


Fallopian  tubes,  tumors  of,  solid,  diag- 
nosis of,  .587 
False  passage  in  urethra.     See  Urethra, 

false  passage  in. 
Fascia;  of  perineum,  423 
Fatty  casts  in  urine,  466 
Females,  projjhylactic  treatment  of,  after 

coitus,  486 
Fenwick,  solitary  vesical  ulcers  of,  774 
Fibroma  of  bladder,  778 
Filaments,    laboratory   examination    of, 

457 
Filariasis  of  kidney,  936 
Fihform  urethra,  urethroscopy  of,  667 
Filiforms  in  urethral  stricture,  347 
Fistula  of  ureter,  840 
Follicular  cystitis,  766 

cysts  of  urethra,   urethroscopy  of, 

667 
periurethral  abscess,  101 
prostatitis,  acute,  117 
chronic,  125 
diagnosis  of,  119 
subacute,  117,  118 
Folliculitis,  gonococcal  acute,  treatment 
of,  100 
chronic,  treatment  of,  100 
paraurethral,  99 

acute,  treatment  of,  100 
chronic,  100,  310 

treatment  of,  100 
definition  of,  99 
diagnosis  of,  100 
etiology  of,  99 
pathology  of,  99 
symptoms  of,  100 
varieties  of,  99 
periurethral,  106.    See  also  Littritis. 
acute,  106 
chronic,  108 
treatment  of,  108 
preputial,  97 

acute,  treatment  of,  100 
chronic,  98,  310 

treatment  of,  100 
diagnosis  of,  98 
etiology  of,  98 
pathology  of,  98 
sj-mptoms  of,  98 
varieties  of,  98 
urethral,  chronic,  312 
Foreign  bodies  in  bladder,  799 
treatment  of,  808 
Fuller's  operation  of  vesiculotomj',  138 
Funiculitis,  chronic,  324 
diagnosis  of,  327 
etiology  of,  324 


97-2 


INDEX 


Fiinioulitis,  chronic,  occurrence  of,  324 

pathology  of,  320 

sjTiiptonis  of,  326 

treatment  of,  327 

varieties  of,  324 
complication  of  epididymitis,  153 
Fused  kidney,  939 


G 

Gaix-bi.adder  disease,  right  pyonephro- 
sis and, 185 
Glandular   complications   of   gonococcal 
acute  urethritis,  10(3 
cystitis,  7tk> 
Gleet  ,"358 

Glycosuria,  artificial  temporary,  849 
physical  basis  of,  849 
technic  of,  850 
Gonococcal  abscess  of  uterus,  010 
acute  balanitis,  91 

comphcations  of,  93 
diagnosis  of,  94-90 
cow'pcritis,  109 

treatment  of,  112 
cystitis,  treatment  of,  173 
epididymitis,  140 
littritis,  100-109 

treatment  of,  108 
lymi)hangeitis  of  penis,  104 
treatment  of,  105 
paraphimosis,  treatment  of,  88 
proctitis,  209 

complications  of,  212 
,  diagnosis  of,  212 

etiology  of,  209 
occurrence  of,  209 
pathology  of,  210 
symptoms  of,  210 
termination  of,  211 
treatment  of,  215 
varieties  of,  210 
prostatitis,  116 

pathology  of,  117 

treatment  of,  121 

varieties  of,  117 

pyeUtis,  treatment  of,  188 

pyelonephritis,     treatment    of, 

188 
spermatocystitis,   diagnosis   of, 
137 
treatment  of,  134 
stomatitis,  208 

diagnosis  of,  208 
treatment  of,  209 
ureteritis,  treatment  of,  188 
urethritis,   anterior,   symptoms 
of,  39 
treatment  of,  53 
bacteriology  of,  24 
etiology  of,  21 
management  of,  47,  55 
pathology  of,  31 
posterior,  complications  of, 
201 


Gonococcal     acute,    urethritis,    jiroiihy- 
laxis  of,  47 
treatment  of,  47 
abortive,  47-52 
conservative,  53-55 
curative,  52-56 
local,  00 
systemic,  59 
urethrocystitis,  163 
diagnosis  of,  165 
pathology  of,  Ui4 
symptoms  of,  164 
treatment  of,  173 
aortitis,  225 
arthralgia,  252 
arthritis,  248 
l)acten'iiiia,  225 
bacterin,  513 
bursitis,  248 
cervicitis,  547 

aftertreatnient  of,  555 
chronic,  549 
cure  of,  550 
diagnosis  of,  551 

differential,  551 
hydrotherapy  of,  553  . 
mctlication  in,  553 
l^athology  of,  547 
relapsing,  550 
significance  of,  547 
surgery  of,  555 
symjitoms  of,  548 
treatment  of,  552 
varieties  of,  547 
chondritis,  248 
choroiditis,  240 
chronic  cowperitis,  112 

treatment  of,  112 
cystitis,  treatment  of,  173 
littritis,  treatment  of,  108 
lymphangeitis  of  penis,  105 
treatment  of,  106 
prostatitis,  120 

treatment  of,  121 
pj-eUtis,  treatment  of,  188 
pyelonephritis,     treatment    of, 

188 
ureteritis,  treatment  of,  188 
urethritis,  264 
anterior,  264 
granulomata  in,  268 
papillomata  in,  268 
pathology  of,  33 
posterior,  204,  268 
cure  of,  301 
diagnosis  of,  291 
symptoms  of,  269,  288 
treatment  of,  289 
urethrocystitis,    treatment    of, 
173 
condylomata  acuminata  in  female, 
599 
diagnosis  of,  602 
etiology  of,  600 
surgery  of,  603 
symptoms  of,  600 


INDEX 


973 


Gonococcal    condylomata  acuminata  in 
female,  treatment  of,  ()()2 
conjunctivitis,  241 
cystitis,  766 
acute,  766 
chronic,  766 
in  female,  .598 
encephalitis,  239 
endocarditis,  224 
endometritis,  556 
acute,  559 

symptoms  of,  558 
treatment  of,  562 
aftertreatment  of,  565 
chronic,  558,  559 

curettage  in,  565 
hydrotherapy  of,  563 
medication  in,  563 
surgery  of,  564 
symptoms  of,  560 
treatment  of,  563 
diagnosis  of,  561 

differential,  561 
etiology  of,  556 
hydrotherapy  of,  562 
hysterectomy  in,  573 

aftertreatment  of,  576 
cure  of,  576 
subtotal,  575 
total,  574 
medication  in  ,563 
pathology  of,  557 
prophylaxis  of,  562 
sigm'ficance  of,  556 
varieties  of,  556 
hydroarthrosis,  254 
infection  after  menopause,  615 
age  as  a  factor  in,  614 
in  childhood,  614 
extragenital,  615 
genital,  614 
urinary,  615 
urogenital,  614 
of  female,  compUcations  of,  597 
extragenital,  597 
genital,  599 
local,  599 
systemic,  599 
urinary,  597 
in  old  age,  615 
in  pregnancy,  613 
in  puerperium,  613 
of  uterine  appendages,  577 
acute,  580 
chronic,  582,  590 
cure  of,  590 
curettage  in,  592 
definition  of,  577 
diagnosis  of  ,584 

differential,  585 
etiology  of,  577 
hydrotherapy  of,  588 
medication  in,  588 
oophorectomy  in,  594 
pathology  of,  578 
relapsing,  583 


Gonococcal  infection  of  uterine  appen- 
dages,  salpingec- 
tomy in,  592 
surgery  of,  589 

conservative,  595 
radical,  596 
symptoms  of,  581 
synonyms  of,  577 
treatment  fif,  588 
types  of,  577 
uterine  surgery  in,  595 
varieties  of,  577 
inflammation  of  vulvovaginal  glands, 
603 
acute,  605 

aftertreatment  of,  610 
chronic,  606 
cure  of,  610 
cystic,  606 
diagnosis  of,  606 
differentiation  of,  607 
medication  in,  609 
pathology  of,  604 
significance  of,  604 
surgery  of,  609 
symptoms  of,  604 
treatment  of,  608 
varieties  of,  604 
iritis,  240 

lesions  of  female  urethra,  678 
of  urethroscopy,  643 
attachment  of,  643 
color  of,  643 
elasticity  of,  644 
folds  of,  644 
glands  of,  644 
gloss  of,  644 
thickness  of,  643 
vascularity  of,  643 
meningitis,  239 
metastatic  abscess,  235 
metritis,  566 
acute,  566 

compUcations  of,  567 
etiology  of,  566 
hydrotherapy  of,  570 
medication  in,  570 
pathologj^  of,  566 
significance  of,  566 
surgery  of,  570 
sj-mptoms  of,  567 
treatment  of,  570 
chronic,  568 

curettage  in,  572 
etiologj^  of,  568 
heliotherapy  of,  571 
hj'drotherapj'  of,  571 
medication  in,  571 
pathologj'  of,  568 
significance  of,  568 
surgerj'  of,  572 
s3'mptoms  of,  568 
trachelectomy  in,  572 
treatment  of,  571 
diagnosis  of,  568 
differential,  569 


974 


INDEX 


Gonococcal  metritis,  treatment  of,  569 
myocarditis,  224 
myositis,  248 
neuralgia,  240 
neuritis,  240 
osteoarthritis,  252 
pericarditis,  224 
perichondritis,  248 
periostitis,  248 
peritonitis,  217 
in  female,  012 

diagnosis  of,  613 
etiology  of,  612 
pathology  of,  1)12 
symptoms  of,  612 
treatment  of,  613 
l^himosis,  treatment  of,  86 
phlebitis,  225 
pleuritis,  238 
polyarthritis,  252 
pniritus  of  vulva,  li03 

treatment  of,  603 
pyelitis  in  female,  598 
rheumatism,  248 
rhinitis,  238 
septicemia,  225 
spondj'loarthritis,  253 
syno^^tis,  252 
tenosjTiovitis,  248 
thrombosis,  225 
toxemia,  225 
urethritis  in  female,  531,  598 

aftertreatment  of,  535 
chronic,  534 
cure  of,  535 
diagnosis  of,  532 
medication  in,  534 
surgery  of,  534 
sjonptoms  of,  531 
treatment  of,  533 
varieties  of,  531 
vaccine,  513 
vaginitis,  538 

aftertreatment  of,  546 
cure  of,  546 
diagnosis  of,  540 

differential,  541 
hydrotherapy  of,  543 
medication  in,  545 
pathology  of,  538 
significance  of,  538 
surgerj^  of,  546 
symptoms  of,  539 
treatment  of,  542 
vulvitis,  535 
acute,  536 

aftertreatment  of,  538 
chronic,  536 
cure  of,  538 
diagnosis  of,  536 
hj'drotherapy  of,  537 
medication  in,  537 
significance  of,  535 
surgerj^  of,  538 
sjTTiptoms  of,  535 
treatment  of,  536 


Gonococcal  vulvitis,  varieties  of,  535 
Gonococcus.  21,  24 

associated  infections  of,  in  female, 
till 
definition  of,  611    ■ 
etiology  of,  611 
occurrence  of,  611 
pathology  of,  611 
in  blood,  complement  fixation  test 

for,  479 
characters  of,  cultural,  26 
mor]ihological,  25 
natural,  24 
in  dried  pus,  ilemonstration  of,  474 
immunization  to,  dangers  of,  516 

reaction  to,  516 
method  of  Gram-staining  of,  25 
products  of,  515 
extracts  of,  515 
filtrates  of,  515 
in  luine,  470 

demonstration  of,  474 
Gonorrhea.     Sec  also  Urethritis, 
age  as  factor  in,  614 
chronic,  358.  See  Urethritis,  chronic, 
complement   fixation   test  in  diag- 
nosis of,  33,  39 
complications  of,  extragenital,  diag- 
nosis of,  480 
genital,  diagnosis  of,  480 
sexual,  diagnosis  of,  480 
discharge  in,  41 
in  female,  481 

bacteriology  of,  527 
diagnosis  of,  481 
etiology  of,  527 
pathology  of,  528 
sites  of  infection  in,  481 
specimens,  source  of,  481 
symptomatology  of,  529 
instructions  to  those  having,  56,  358 
lymphangeitis  in,  41 
metastases  of,  serotherapy  of,  521 
prophylaxis  of,  483 
after  coitus,  485 
personal,  483 

significance  of,  483 
technic  of,  484 
social,  486 

importance  of,  486 
technic  of,  488 
with  condom,  485 
rectal.    See  Proctitis,  gonococcal, 
"shreds"  in,  41 
technic  of  obtaining  smears  from, 

480 
toxemia  of,  serotherapy  of,  521 
treatment  of,  483 
abortive,  490 

cases  suited  for,  490 
methods  of,  490 
purposes  of,  490 
curative,  492 

methods  of,  492 
purpose  of,  492 
electrotherapy  in,  499 


INDEX 


975 


Gonorrhea,  treatment  of,  electrotherapy 
in,  faradic,  500 

galvanic,  500 

status  of,  499 

varieties  of,  500 
expectant,  492 
hydrotherapy  in,  498 

cases  suited  for,  498 

purposes  of,  498 

technic  of,  499 
indications  of,  494 

pathologic,  494 

symptomatic,  494 
by  irrigation,  abortive,  491 

curative,  493 
local,  505 
management  of,  495 

definition  of,  495 

diet  in,  496 

dressings  in,  497 

drinks  in,  496 

hygiene  of,  495 

importance  of,  495 

nursing  in,  496 

rest  in,  495 

tobacco  in,  496 
massage  in,  497 

cases  suitable  for,  498 

forms  of,  498 

purposes  of,  498 

technic  of,  498 
operative,  509 

aftertreatment  of,  510 

cure  in,  510 
palliative,  491 

methods  of,  491 

purpose  of,  491 
phototherapy  in,  499 

action  of,  499 

cases  suited  for,  499 

definition  of,  499 

technic  of,  499 
physical  measures  in,  497 
purposes  of,  497 
preventive,  483 
serotherapy  in,  512 

contraindications  for,  522 

indications  for,  518 
surgical,  506 

nonoperative,  506 
sjrmptomatic,  494 

methods  of,  494 

purposes  of,  494 
systemic,  504 
test  in  diagnosis  of,  479 
Gonorrheal  periproctitis,  212 

stricture  of  rectum,  212  , 

Granular  casts  in  urine,  465 

cystitis,  766 
Granulations  in  posterior  urethra,  654 
Granulomata  in  chrom'c  urethritis,  268 

H 

Hagner's  method  of  treatment  of  neo- 
plasms of  bladder,  784 


Hagner's  operation  for  epididymotomy, 

160 
Ilarrar's  method  of  treating  gonococcal 

sepsis,  233-235 
Heliotherapy,  499.     See  Phototherapy. 
Hellige's  colorimeter,  856 
Hematology,  863 
chemical,  863 
Hematuria,  renal.     See  Kidney,  hemor- 
rhage from.    • 
from  l-5ilharziasis,  936 
i'roiM  fiJariasis,  936 
in  tumors,  905 
Hemorrhage  from  kidney,  927 
asyndromic,  929 
definition  of,  928 
diagnosis  of,  928 
etiology  of,  928 
painless,  929 

definition  of,  929 
diagnosis  of,  929 
etiology  of,  929 
nephritic,  930 
toxic,  930 
varicose,  931 
papillomatous,  933 
diagnosis  of,  934 
pathology  of,  933 
symptoms  of,  934 
treatment  of,  934 
syndromic,  934 

aneurysmal,  936 
definition  of,  934 
diagnosis  of,  935 
etiology  of,  934 
parasitic,  936 
traumatic,  935 
varieties  of,  934 
synonyms  of,  927 
varieties  of,  928 
varix,  931 

course  of,  932 
diagnosis  of,  932 

differential,  932 
pathogenesis  of,  931 
symptoms  of,  931,  932 
treatment  of,  933 
urethral.    See  Urethra,  hemorrhage 
from. 
Hemorrhagic  cystitis,  765 
Hernia  of  scrotum,  differentiation  from 

epididymitis,  156 
Herpetic  acute  urethritis,  patholog>'  of, 
30 
SATnptoms  of,  39 
urethritis,  uretliroscopj*  of,  661 
History  blank  for  diagnosis,  429 
Horseshoe  kidney,  939 
HyaUne  casts  in  urine,  464 
Hydatids  of  kidney.     See  Echinococcus. 
H^^droarthrosis,  gonococcal,  254 
Hydrocele,  acute,  151 

traumatic.  153 
Hj'dronephrosis,  893 
cystoscopy  in,  898 
definition  of,  893 


976 


IXDEX 


Hydronephrosis,  diagnosis  of,  900 
differential,  901 

etiology  of,  S94 

funt'tidiial  renal  tests  in,  899 

physical  examination  in,  898 

symptoms  of,  895 

treatment  of,  902 

ureteral  eatheterism  in,  898 

urinalysis  in,  89S 

varieties  of,  894 
Hydrotherapy   of   gonococcal    cervicitis, 

endometritis,  .5()2,  oti,'} 
infection  of  uterine  appendages, 

588 
metritis,  570,  571 
urethritis,  498 
vaginitis,  543 
vulvitis,  537 
of  i>eriurethral  abscess,  103 
of  spermatocystitis,  135 
Hj'peremia  of  bladticr,  active,  757 

passive,  758 
Hypertrophy  of  prostate,  123,  943 
cystoscopy  of,  943 
diagnosis  of,  951 
sym])toms  of,  943 
treatment  of,  951 
Hysterectomy   for   gonococcal   endome- 
tritis, 573 


Immunity,  475 
active,  513 
pa.ssive,  517 
Immunization  to  gonococcus,  dangers  of, 
5  If) 
reaction  to,  516 
Indigocarmine  test  of  renal  function,  851 
advantages  of,  852 
phj^sical  basis  of,  851 
technic  of,  851 
Infarct  of  kidney,  septic,  870 
definition  of,  870 
etiology  of,  872 
symptoms  of,  872 
syndrome  of,  872 
treatment  of,  873 
Infection,    urinary,    412.      See    Urinary 

infection. 
Inflammation  of  urethral  glands,  chronic, 
267 
of  vulvovaginal  glands,  gonococcal, 
603 
Inflammatory  stricture  of  urethra,  340, 

349 
Injections  in  treatment  of  acute  urethri- 
tis, 61-64,  69 
in  treatment  of  jAimosis,  86 
Inoculation  with  vaccine,  technic  of,  514 
Instillation,  instruments  for,  294-298 
Instillations     in     treatment     of     acute 

urethritis,  69 
Iritis,  gonococcal,  240 

electrotherapy  of,  241 


Iritis,  gonococcal,  treatment  of,  241 
Irrigating  sound,  IVilersen's,  114 
Irrigation  of  bladder,  3()8,  371 
in  ciu'onic  urethritis,  286 
method,  general  principles  of,  300 

in  treatment  of  urethritis,  70,  79 
subprejiutial,  8(),  97 

Pedersen's  method,  97 
in  treatment  of  ])him()sis,  86 
with  catheter  in  treatment  of  ure- 
thritis, 64,  69,  79 


Janet  method  in  al)nrtivc  treatment  of 

gonorrhea,  49 
Janet-Frank    syringe    in    treatment    of 

urethritis,  61 
Janet-^'alcntine  nu^thod  in  urethritis,  71, 

80 


Kapsammer's  phloridzin  test,  850 
Kelly's  apparatus  in  ureteral  catheteri- 
zation, 832 
introduction  of,  832 
withdrawal  of,  832 
Keyes-Ultzmann  syringe,  295 
Kidney,  BiLharziasis  of,  937 
cysts  of,  937 
echinococcus  of,  939 
filariasis  of,  936 
functional  capacity  of,  841 
tests  of,  812 

comparison  between,  862 
fused,  939 

hemorrhage  from,  927 
asyndromic,  929 
definition  of,  928 
diagnosis  of,  928 
etiology  of,  928 
painless,  929 

definition  of,  929 
diagnosis  of,  929 
etiology  of,  929 
nephritic,  930 
toxic,  930 
varicose,  931 
papillomatous,  933 
diagnosis  of,  934 
pathology  of,  933 
symptoms  of,  934 
treatment  of,  934 
syndromic,  934  ^ 
^  aneurysmal,  936 

definition  of,  934 
diagnosis  of,  935 
etiology  of,  934 
parasitic,  936 
traumatic,  935 
varieties,  934 
synonyms  of,  927 
varieties  of,  928 
horseshoe,  939 


INDEX 


977 


Kidney,  lithiasis  of,  909 
calculi  of,  \)\'.'> 

chemical  composition  of,  9!;') 
definition  of,  909 
diagnosis  of,  92ii 

differentiid,  923 
etfology  of,  912 
patho{i;(!n(!siK  of,  912 
symptoms  of,  914 
cystoscopic,  918 
objective,  917 
radiofi;i'a,p}iic,  919 
subjective,  914 
urinary,  917- 
treatment  of,  926 
neoplasm  of,  903 

definition  of,  903 
diagnosis  of,  907 

differential,  908 
hematuria  in,  905 
pyonephrosis    and,    differentia- 
tion of,  186 
radiography  in,  907 
symptoms  of,  objective,  906 

subjective,  904 
treatment  of,  909 
urinalysis  in,  907 
polycystic,  938 

diagnosis  of,  938 
pathogenesis  of,  938 
symptoms  of,  938 
treatment  of,  938 
rare  diseases  of,  927 
septic  infarct  of,  870 

definition  of,  870 
etiology  of,  872 
symptoms  of,  872 
sj^ndrome  of,  872 
treatment  of,  873 
syphilis  of,  939 
tuberculosis  of,  881 

bacteriology  of,  891 

definition  of,  881 

diagnosis  of,  891 

differentiation  of,  891 

etiology  of,  881 

functional       renal      tests      in, 

890 
occurrence  of,  881 
radiography  in,  890 
symptoms  of,  objective,  886 

subjective,  881 
treatment  of,  892 
ureteral  catheterism  in,  888 
urinalysis  in,  889 
unilateral,  939 
varix,  hemorrhage  in,  931 
course  of,  932 
diagnosis  of,  932 

differential,  932 
pathogenesis  of,  931 
symptoms  of,  931 
treatment  of,  933 
Kollmann's  irrigating  dilators,  287 

multiple  glass  test,  456 
Kromeyer's  multiple  glass  test,  456 
62 


Lai'Avkttk  mixtiu'c,  68 
Jycggiiigs  for  cyst,t)S(U)py,  721 
Leukoplakia,  of  bladder,  802 
Lipuria  in  iiritK;,  -158 
Lithiasis  of  bladdc^r,  792 

cystoscopy  of,  792 
diagnosis  of,  796 
etiology  of,  795 
manag(!inent  of,  797 
treatment  f)f,  797 
varieties  of,  795 
of  kidney,  909 

calculi  of,  913 

chemical      conj])ositi(jn     of. 

913 
diagnosis  of,  923 

differential,  923 
etiology  of,  912 
pathogenesis  of,  912 
symptoms  of,  914 
cystoscopic,  918 
objective,  917 
radiographic,  919 
subjective,  914 
urinary,  917 
treatment  of,  926 
of  prostate,  963 

diagnosis  of,  964 
etiology  of,  963 
pathology  of,  963 
symptoms  of,  963 
treatment  of,  964 
Littritis,  106 

aftertreatment  of,  109 
chronic,  108,  267,  312 
treatment  of,  108 
cure  of,  evidences  of,  109 
diagnosis  of,  107 
electrotherapy  of,  108 
gonococcal,  106-109 

acute,  treatment  of,  108 
chronic,  treatment  of,  108 
pathology  of,  106 
serotherapy  of,  108 
surgical  management  of,  109 
symptoms  of,  107 
treatment  of,  108 

instrumental,  109 
with  retention  (folhculitis),  106 
Liver,  enlarged,  differentiation  from  right 

pyonephrosis,  185 
Lohnstein's  multiple  glass  test,  456 
Luy's  multiple  glass  test,  452 
Ljauphadenitis  of  penis.    See  Lj^mphan- 

geitis. 
Lymphangeitis  of  penis,  acute,  104 
diagnosis  of,  105 
gonococcal,  104 
treatment  of,  105 
aftertreatment  of,  106 
chronic,  105,  311 

treatment  of.  105 
cure  of,  evidences  of,  106 
in  gonorrhea,  41 


978 


INDEX 


M 


Magxksivm  sulphate,  intravenous  injec- 
tions in  gonococcal  sepsis,  233 
Maisonneuve's     internal     urethrotomy, 

393 
Malaria  as  a  caiLse  of  urethritis,  22 
Males,  projihylactic   treatment  of,  after 

coitus,  485 
Martin's  operation  of  epididyniovasos- 

toniy,  101 
Massage,  diagnostic,  272 
of  ])rostate,  272 
of  vesicles,  272 
in  gonorrhea,  497 
in  jirostatitis,  122 
in  sperinatocystitis,  135 
Meatoscoi)y,  ureteral,  820 
Meatotoniy,  i>r(>liniinary,  376,  388 
aftertreatnient  of,  389 
instruments  for,  388 
Membranous  cj^titis,  765 

extravasation  of  urine,  424 
urethra,  urethroscopic  lesions  of,  567 
urethrosco})y  of,  641 
Meningitis,  gonococcal,  239 
Metastatic  abscess,  gonococcal,  235 
^Metritis,  gonococcal,  566 
acute,  566 

complications  of,  567 
etiology  of,  566 
hydrotheraj^y  of,  570 
medication  in,  570 
pathologj'  of,  500 
significance  of,  566 
surger}-  of,  570 
symptoms  of,  567 
treatment  of,  570 
aftertreatnient  of,  571 
chronic,  568 

curettage  in,  572 
etiology  of,  568 
heliotherapy  of,  571 
hydrothcrajiy  of,  571 
medication  in,  571 
l^athology  of,  568 
significance  of,  568 
surgerj^  of,  572 
symptoms  of,  568 
trachelectomy  in,  572 
treatment  of,  571 
cure  of,  572 
diagnosis  of,  568 

differential,  569 
treatment  of,  569 
Micrococcus  blennorrhea;,  24 

catarrhalis,  20,  22,  36,  37,  43,  44 
in  acute  proctitis,  213 
cultural  qualities  of,  23 
morphology'  of,  23 
staining  properties  of,  23 
cereus  albus,  22 
fullax  in  acute  urethritis,  22 
gonorrhea;,  24 
pyogenes  aureus,  22 
Morning  drop,  270 


Morris's  method  of  treating  peritonitis, 

222 
Multiple  glass  tests,  271-273,  450-456 
classes  of,  450 
general  jirinciples  of,  450 
Kolhnann's,  450 
Kromeyer's,  450 
Lohnstein's,  456 
Luy's,  452 
two-glass,  451 
with  dyes,  456 
Woll)arst's,  452 

Pedersen's  modifica- 
tion of,  453 
Young's,  456 
Myocarditis,  gonococcal,  224 
Myoma  of  l)ladder,  778 
Myositis,  gonococcal,  248 
treatment  of,  257 


N 


Neisseria  gonorrhea;,  24 
Neoplasm  of  bladder,  776 
diagnosis  of,  777 
varieties  of,  778 
of  kidney,  903 

definition  of,  903 
diagnosis  of,  907 

difTerential,  908 
hematuria  in,  905 
radiography  in,  907 
sj'mi)tonis  of,  objective,  906 

subjective,  904 
treatment  of,  909 
urinalysis  in,  907 
varieties  of,  903 
of  prostate,  957 

diagnosis  of,  960 
radium  in,  959 
of  urethra  in  female,  urethroscopy 
of,  679 
Neoplastic  cervicitis,  552 
epididymitis,  156 

spermatocystitis,  diagnosis  of,  132 
urethritis,  urethroscopy  of,  667 
warts,  205 
Nephrectomy  in  renal  infection,  190 
aftertreatnient  of,  194 
drainage  in,  194 
evidences  of  cure  in,  194 
forms  of,  190 
incisions  in,  191 
technic  of,  190-195 
Nephrotomy  in  renal  infection,  195 
aftertreatnient  in,  196 
cautions  in,  916 
evidences  of  cure  in,  197 
technic  of,  195-197 
Neuralgia,  gonococcal,  240 
Neuritis,  gonococcal,  240 
Nonbacterial  nongonococcal  acute    ure- 
thritis, 21 
symptoms  of,  30 


INDEX 


979 


Nongonococcal    acute    uroithritl.s,    bac- 
terial, 22 
bacteriology,  of  21 
complications  of,  2()0 
etiology  of,  19 
nonbacterial,  21 
symptoms  of,  3() 
chronic  urethritis,  264,  341 
treatment  of,  301 
varieties  of,  301 
conjunctivitis,  242 
epididymitis,  etiology  of,  148 
lesions  of  female  urethra,  678 
urethritis  in  female,  529 

urethroscopic  lesions  of,  651 
Nursing  in  gonorrhea,  496 


Obstruction  of  ureter,  835.    See  Ureter, 

obstruction  of. 
Ointment  sounds,  284 

Pedersen's,  295 
Young's,  295 
One-journey  plan,  371 
Oophorectomy  in  gonococcal  infection, 

594 
Operation  vs.  Dilatation  for  stricture,  363 
Orchitis,  chronic,  324 

diagnosis  of,  327 
etiology  of,  324 
occurrence  of,  324 
pathology  of,  326 
symptoms  of,  326 
treatment  of,  327 
complication     of     urethritis.       See 

Epididymitis, 
traumatic,  153 
Organic  stricture  of  urethra,  338,  343 
Orrhodiagnosis,  475 
Orrho therapy.     See  Serotherapy. 
Osteoarthritis,  gonococcal,  252 
Otis's  internal  urethrotomy,  391 
Oudin  high-frequency  current,  501 

in    internal    urethro- 
tomy, 394 
Ovarian  tumors,  diagnosis  of,  586 


Painless  hemorrhage  from  kidney,  929 
Papilloma  of  bladder,  778 

in  chronic  urethritis,  268 

renal,  933 

hemorrhage  from,  934 

of  urethra,  urethroscopy  of,  669 
in  female,  679 
Papillomatous  balanitis,  diagnosis  of,  96 
Paraphimosis,  acute,  83 

chronic,  308 

definition  of,  83 

diagnosis  of,  84 

etiology  of,  83 

symptoms  of,  83 


Parai)liirnoHis,  trciatmont  of,  HS 
I*arasit(!8  of  urine,  470 
Parasitic  diseases  of  bladder,  803 
hemorrhag(!  from  kidney,  936 
Paraurethral  folliculilis,  acute,  09 

chronic,  100,  310 
Parenchymatous  prostatitis,  117,  119 
diagnosis  of,  120 
.symptoms  of,  119 
Pedersen's  ointment  .sound,  295 

method  of  subpreputial  irrigation,  97 
seven-glass  test,  168,  455 
syringe  in  treatment  of  ur(;thritis,  61 
Pelvic  celluUtis,  diagnosis  of,  .587 
Pelvis,  radical  surgery  of,  596 
Penile  extravasation  of  urine,  424 
urethra,  urethroscopy  of,  641 
Penis,  Ijmaphangeitis  of,  acute,  104 

diagnosis  of,  105 
Periarthritis.     See  Arthritis. 
Pericarditis,  gonococcal,  224 
Perichondritis,  gonococcal,  248 
Perineum,  fasciaj  of,  423 
Periostitis,  gonococcal,  248 
Periproctitis,  gonorrheal,  212 
Peritonitis,  gonococcal,  217 

aftertreatinent,  tf)f  223 
diagnosis  of,  219 

differential,  219 
electrotherapy  of,  220 
etiology  of,  218 
general,  in  female,  612 

diagnosis  of,  613 
etiology  of,  612 
pathology  of,  612 
symptoms  of,  612 
treatment  of,  613 
laparotomy  in,  221 
medication  in,  220 
Morris's    method    of    treating, 

222 
occurrence  of,  217 
pathology  of,  218 
phototherapj'  of,  220 
significance  of,  217 
surgery  of,  221 
symptoms  of,  218 
treatment  of,  210 
curative,  220 
generalized,  222 
locahzed,  222 
plastic,  222 
varieties  of,  218 
Periurethral  abscess,  clironic,  311 
foUicular  abscess,  101 
folUcuUtis,  acute,  106 
chronic,  108 
treatment  of,  108 
Periurethritis,  acute,  107 

chronic,  267 
Pfeiffer's  phenomenon,  475 

streptobaciUus  in  acute  urethritis,  23 
Phagocj-te  count,  512 
Phenacetin  in  treatment  of  chordee,  58 
Phenolsulphonephthalein  test,  852 
advantages  of,  852 


9S0 


IXDEX 


Phenolsulphoneplitlialoin  test,  clisailvan- 
tajies  i)f,  852 
Pedoi-son's  oliart  for,  SoS-S62 
physical  l)a.sis  of,  852 
teohiiic  of,  853 
Pliiniosis,  S3 

acuto,  treat iiiiMit  of,  86 
c'hn)iiic,  308 

treatment  of,  86 
circumcision  in,  87 
cure  in,  oviciences  of,  88 
definition  of,  83 
diagnosis  of,  84 
etiologA"  of,  83 

fionccoccal,  treatment  of,  86 
irrifialion  teclinic  in  treatment  of,  8(i 
symptoms  of,  83 
Phlel)itis,  gonococcal,  225 
Phloriclzin  test,  850 

Casper's,  850 
deductions  from,  851 
Kapsammer's,  850 
results  of,  851 
Phosphates,  ammoniomagnesium,  468 

calcium  amorphous,  4(iS 
Phosphaturia  in  s])ermatocystitis,  129 
Phototherapy  ia  gonorrhea,  499 
Phyla  cogens,  515 
Pilcher's  bag,  954 
Pleuritis,  gonococcal,  238 
Plica  interureterica,  761 

ureterica,  761 
Polyarthritis,  gonococcal.  252 
Polycystic  kidney,  938 

diagnosis  of,  938 
pathogenesis  of,  938 
symptoms  of,  938 
treatment  of,  938 
Polypi  of  urethra,  269 

urethroscoin'  of,  670 
in  female,  679 
Polypoid  masses  in  posterior  urethra,  655 
Polj'uria,  artificial,  847 

advantages  of,  849 
deduct  ins  from,  849 
disadvantages  of,  849 
physical  basis  of,  847 
results  of,  849 
technic  of,  847 
Posthitis,  89 

acute,  treatment  of,  96 
chronic,  96,  308 

treatment  of,  96 
gonococcal.    See  Balanitis,  gonococ- 
cal, 
relapsing,  308 
Pregnancy,  gonococcal  infection  in,  613 

tubai,  diagnosis  of,  587 
Prepuce,  normal  flora  of,  21 
Preputial  folliculitis,  acute,  97 

chronic,  9S,  311 
Proctitis,    catarrhal,    differentiation    of, 
from  gonococcal,  214 
chancroidal,  differentiation  of,  from 

gonococcal,  215 
gonococcal  acute,  209 


Proctitis,    gonococcal   acute,    aftertreat- 
ment  of,  217 
complications  of,  212 
cure  of,  evidences  of,  217 
diagnosis  of,  212 

differential,  214 
etiology  of.  209 
hydrotherapy  of,  216 
occurrence  of,  209 
pathology  of,  210 
siu'gery  of,  216 
.symptoms  of,  210 
termination  of,  211 
treatment  of,  215 
varieties  of,  210 
.syphilitic,    differentiation    of,    from 
gonococcal,  214 
Prostate  gland,  436 

abscess  of,  treatment  of,  125 
anatomy  of,  436 
diseases  of,  943 
examination  of,  437-441 
hypertro])hy  of,  913 
cystoscoin'  of,  943 
diagnosis  of,  951 
.symptoms  of,  943 
treatment  of,  951 
lithiasis  of,  963 

diagnosis  of,  964 
etiology  of,  963 
l)athology  of,  963 
symjitcjms  of,  963 
treatment  of,  964 
massage  of,  diagnostic,  272 
neojilasm  of,  957 

diagnosis  of,  960 
differential,  960 
radium  in,  959 
utricular  cyst  of,  urethroscopy 
of,  666 
Prostatic  electrodes,  502 

extravasation  of  urine,  424 
l)unch.  Young's,  963 
secretion.    Young's   method   of   ob- 
taining, 317 
urethra,     diseases    of,     cystoscopic 
treatment  of,  656 
urethroscopy  of,  640 
Prostatitis,  116 

aftcrtreatment  of,  125 
chronic,  120,  313,  956 
cystoscopy  of,  956 
diagnosis  of,  317 
etiology  of,  313 
pathologj'  of,  313 
symptoms  of,  314 
treatment  of,  121,  317 
cure  of.  evidences  of,  125 
diagnosis  of,  119 

microscopic,  121 
electrotherapy  of,  123 
etiology  of,  1 16 
follicular,  acute,  117 
chronic,  125 
diagnosis  of,  119 
subacute,  117,  118 


IN  HEX 


981 


Prostatitis  following   trciitmont  of  strit;- 
turo,  4H) 
diagnosis  of,  417 
etiology  of,  417 
treatment  of,  4 1  <S 
gonococcal  acute,  1 17 

pathology  of,  117 
hydrotherapy  of,  123 
massage  in,  122 
occurrence  of,  IK) 
parenchymatous,  acut(!,  117,  119 

diagnosis  of,  120 
rectal  signs  of,  118 
secretion  of,  examination  of,  '4 1 7 
suppurative,  ti'eatirient  of,  125 
symptoms  of,  117 
treatment  of,  121-126 
curative,  122 
local,  124 
medicinal,  124 
tuberculous,  957 

diagnosis  of,  957 
urinary  signs  of,  118 
Pruritus  of  vulva,  gonococcal,  603 

treatment  of,  603 
Pseudodiphtheria  bacilli,  acute  urethritis 

and,  22 
Puerperium,  gonococcal  infection  in,  613 
Purjjura  of  bladder,  801 
Pus  casts  in  urine,  466 
cells  in  urine,  460 

dried,  gonococcus  in,  demonstration 
of,  474 
Pyelitis,  177 

acute,  diagnosis  of,  183 
ascending,  180 
catarrhal  acute,  868 

definition  of,  868 
•    diagnosis  of,  869 
differentiation  of,  869 
etiology  of,  868 
pathogenesis  of,  868 
of  pregnancy,  870 
syndrome  of,  869 
treatment  of,  870 
chronic,  329.    See  Ureteritis,  chronic, 
descending,  182 

differentiation  from  cystitis,  172 
etiology  of,  178 

gonococcal,  acute,  treatment  of,  188 
chronic,  treatment  of,  188 
in  female,  598 
gonococcus  as  cause  of,  178 
occurrence  of,  177 
pathology  of,  179 
pyogenic  cocci  as  cause  of,  178 
symptoms  of,  180 
termination  of,  182 
Pyelonephritis,  329 

acute,  diagnosis  of,  183 

ascending,  181 

chronic,  diagnosis  of,  183 

descending,  182 

differentiation  from  cystitis,  172 

essence  of,  179 

gonococcal  acute,  treatment  of,  188 


Pyelonephritis,       gonococcMl        chronif, 
treatinent  of,  188 
invasion  of,  J 81 
l.'iboratory  findings  in,  181 
pathology  of,  179 
suppurative  acute,  873 

definition  of,  873 
diagnosis  of,  877 
etiology  of,  873 
pat  hogenesis  of,  873 
j)liysical    examination    of, 

876 
syndrome  of,  873 
treatment  of,  877 
symptoms  of,  181 
termination  of,  183 
Pyogenic  organisms  in  urine,  471 
urethritiK,  303 
acute,  303 

diagnosis  of,  44 
symptoms  of,  37 
anterior,  303 
chronic,  303 
posterior,  303 
treatment  of,  303 
Pyonephrosis,     877.     See     also     Pyelo- 
nephritis, 
conclusions,  880 
definition  of,  877 
diagnosis  of,  184 

differential,  184-188 
with  radiography,  184 
differentiation  from  cystitis,  172 
etiology  of,  878 
left,  enlarged  spleen  and,  184 
stomach  tumors  and,  185 
nephrectomy  in,  190 
pathology  of,  878 
right,  enlarged  liver  and,  184 

gall-bladder  disease  and,  185 
symptoms  of,  urinary,  879 

vesical,  879 
syndrome  of,  878 
treatment  of,  880 


R 


Radiography,  diagnosis  of  pyonephrosis 
and,  184 
in  lithiasis  of  kidnej',  919 
in  renal  tumors,  907 
in  tuberculosis  of  kidne.y,  890 
Radium  in  cancer  of  bladder,  789 
in  neoplasm  of  prostate,  959 
Rectal  electrotherapy  in  urethritis,  293 
examination  in  stricture  of  urethra, 
348 
Rectum,  chancroid  of,  215 

gonorrheal  stricture  of,  212 
Renal  function,  indigocarmin  test  of,  851 
advantages  of,  852 
physical  basis  of,  851 
technic  of,  851 
phenolsulphonephthalein  test 
of,  852 


9S2 


INDEX 


Renal    function,    phonolsulphonephtha- 
h'in    tost  of,  lulviin- 
tapes  of,  852 
disadvantages  of,  852 
physical  basis  of,  852 
technic  of,  853 
phloriilzin  test  of,  850 
Casper's,  850 
deductions  from,  851 
Kapsanuner's,  850 
results  of,  S51 
tests  of,  in  hyilro nephrosis,  899 
in  tuberculosis  of  kidney, 
890 
functional  diagnosis,  advanced,  844 

essential  data  of,  844 
papilloma,  OolJ 

hemorrhage  from,  934 
Retention  of  urine.     See  iTine,  reten- 
tion of. 
Retrojection,  apparatus  for,  298 
Retroperitoneal    growths,    pyonephrosis 

and,  differentiation  of,  187 
Rheumatism,     gonococcal,     248.     See 
Arthritis, 
aftertreatment  of,  259 
cure  of,  evidence  of,  260 
differentiation     from    simple 

rhciuiiatism,  256 
elect  rot  hera])y  of,  258 
hydrotherapy  of,  258 
mechanotherapy  of,  257 
phototherapy  of,  258 
serotherapy  of,  259 
surgery  of,  259 
treatment  of,  257 
curative,  257 
local,  258 

medicamentous,  258 
pro])hylactic,  257 
simple,    differentiation    from   gono- 
coccal, 256 
Rhinitis,  gonococcal,  238 


Sactos.\lpixx,  diagnosis  of,  586 
Salpingectomy  in   gonococcal   infection, 

592 
Salts,  blood  content  of,  866 
Sandalwood  oil  in  treatment  of  urethritis, 

67 
Sarcoma  of  bladder,  781 

of  urethra,  urethroscopy  of,  674 

in  female,  680 

Schwartz's  complement  fi.\ation  test  in 

gonorrhea,  33,  39 
Scrotum,  edema  of,  in  epididymitis,  151 
erysipelas  of,  simulation  of  epidid- 
ymitis by,  156 
hernia  of,  simulation  of  epididymitis 
by,  156 
Segregators,  urinarj',  704 
Seminal  vesicles,  abscess  of,  130 

massage  of,  diagnostic,  272 


Seminal  vesiculitis,  126.    See  Spevmato- 

cystitis. 
Septicemia,  gonococcal,  225 
definition  i)f,  225 
diay;nosis  of,  229 
elect  rot  lierai)y  of,  231 
etiologv  of,  227 
fatal,  229 

hydrotherapy  of,  230 
intravenous  injections  of  mag- 
nesium sulphate  in,  233 
occurrence  of,  226 
l)athology  of,  228 
jihototherain'  of,  230 
.significance  of,  225 
surgery  of,  232 
symptoms  of,  228 
treatment  of,  230 
Serotherapy  in  gonorrhea,  contraindica- 
tions of,  522 
indications  for,  518 
Serum,  antigonococcic,  517 
Serum  diagnosis,  475 
Seven-glass  test  of  author,  168,  455 
"Shreds"  in  gonorrhea,  41 
Silver  salts  in  treatment  of  urethritis,  66 
Sinclair,  external  lu'ethrotomy  of,  403 
Sodomy,  funnel  shaped  anus  in,  211 

rectal  gonorrhea  and,  211 
Solutions    for    irrigation    treatment    of 
urethritis,  72,  73 
for  local  treatment  of  urethritis,  66, 
69 
Sounds  for  irrigation,  284,  287 

and  dilatation,  370-374 
method  of  passing,  298 
for  ointments,  284 
use  of,  in  acute  prostatitis,  125 
Spasmodic  stricture  of  urethra,  341,  349 
Spermatocystitis,  126 
acute,  127 

complications  of,  131 
diagnosis  of,  131 
differential,  131 
in  nonretention  cases,  131 
in  retention  cases,  131 
aftertreatment  of,  137 
association    of,    with    epididymitis, 

149 
calculous,  132 
chronic,  127,  133,  318 

diagnosis  of,  133,  324 
etiology  of,  319 
pathology  of,  320 
significance  of,  323 
symptoms  of,  322 
treatment  of,  324 
varieties  of,  319 
with  retention,  133 
without  retention,  133 
diagnosis  of,  microscopic,  129 
etiology  of,  126 
gonococcal,  diagnosis  of,  131 
electrotherapy  of,  135 
hydrotherapy  of,  135 
massage  in,  135 


INDEX 


983 


Spermatocystitis,  gonococcal,  treatment 
of,  134 
neoplastic,  diagnosis  of,  132 
occurrence  of,  126 
pathology  of,  127 
retention  of  urine  in,  136 
serotherapy  of,  136 
suppurative,  130 
symptoms  of,  128,  134 
local,  129 
objective,  129 
rectal,  128,  134 
subjective,  128,  134 
urinary,  128,  134 
systemic  management  of,  136 
termination  of,  130 
treatment  of,  134 

instrumental,  137 
local,  136 
tuberculous,  diagnosis  of,  131 

treatment  of,  132 
vasopuncture  in,  137 
vasostomy  in,  137 
vesiculotomy  in,  138-146 
with  retention,  130 
without  retention,  130 
Spirochseta  balantiditis,  29 
Spleen,    enlarged,    differentiation    from 

pyonephrosis,  184 
Spondylarthritis,  gonococcal,  253 
Squier's  method  of  treatment  of  neo- 
plasms of  bladder,  785 
operation  of  vesiculotomy,  143-146 
Staphylococci  in  acute  urethritis,  22 

in  urine,  471 
Sterih'ty  following  epididymitis,  152 
Stomatitis,  gonococcal,  208 
diagnosis  of,  208 
treatment  of,  209 
Stone  searchers,  798 
Streptococcus  in  urine,  471 
Stricture  of  rectum,  gonorrheal,  212 
of  ureter,  834 

diagnosis  of,  835 
etiology  of,  834 
pathology  of,  834 
sequels  of,  834 
treatment  of,  835 
of  urethra,  334 
acquired,  338 
chronology  of,  341 
close,  347 

dilatation  of,  376 
complications  and  sequelae  of, 
418 
diagnosis  of,  420 
differentiation  of,  421 
etiology  of,  419 
pathology  of,  420 
significance  of,  418 
symptoms  of,  420 
treatment  of,  421 
congenital,  338 
cystitis  following  treatment  of, 

416 
definition  of,  334 


Stricture  of  ur(;tlira,  diagnoKJs  of,  353 
differential,  356 
with  rectal  touch,  348 
with  urethroHcofje,  34H 
dilatation  of,  continuous,  383 
due  to  external  pressure,  341, 

350 
edematous,  341,  349 
electrolysis  of,  3H4 

aftertreatment  of,  387 
cases  suited  for,  385 
d'Arsonval,  387 
galvanic,  386 
history  of,  384 
instruments  for,  386 
t^chnic  of,  386 
epididymitis     following     treat- 
ment of,  416 
etiology  of,  334 
in  female,  599 

symptoms  of,  599 
treatment  of,  599 
gonococcal,  differentiation  from 
inflammatory,  356 
from  periurethral,  357 
from  spasmodic,  357 
from  traumatic,  357 
inflammatory,  340,  349 
open,  dilatation  of,  376 
organic,  338,  343 

symptoms  of,  343 
pathology  of,  336 
prevention  of,  358 
prostatitis  following  treatment 

of,  416 
relapse  of,  352 
resection  for,  407 
retention    of    urine    following 

treatment  of,  421 
significance  of,  358 
spasmodic,  341,  349 
termination  of,  351 
tight,  347 

dilatation  of,  379 

\\'ith  miforms,  380 
with  irrigation  sounds, 

379 
with     nonirrigating 

sounds,  382 
with  soft  instruments, 
382 
traumatic,  341,  350 
treatment  of,  358 
accidents  of,  407 
immediate,  362 
methods  of,  362 
operative,  388 
preparatory,  358 
with  cystoscope,  656 
urethritis    following   treatment 

of,  416 
urethrotomy,  external  for,  395 

internal  for,  388 
use  of  metal  dilators  in,  377 
of  soft  dilators  in,  377 
Styptics  for  urethroscopy,  628     , 


084 


IXDEX 


Suliiiri'imtial  irrigation,  SO 

reiloi"sen"s  method  of,  97 
Sugar,  blood  content  of,  SO(i 
Suppurative  aeute  pyelonephritis,  S73 
definition  of,  X7'A 
diapcTiosis  of,  S77 
t'tioloiiy  of,  S7o 
pathogenesis  of,  S7:i 
lihvsieal    exaniination    of, 

S7(i 
syndrome  of,  873 
treatment  of,  S77 
balanitis,  94 

prostatitis,  treatment  of.  I'Jo 
siiermatdcystitis,  lit) 
urethritis,  urethroseopy  of,  ()t)l 
Syndromic  hemorrhage  from  kidney,  934 
Synovitis,  gonococcal,  252 
Syphilis  of  kidney,  939 

of  urethra,  304 
Sjfphilitic  acute   urethritis,  bacteriology 
of,  22 
diagnosis  cf,  45 
etiology  of,  20 
))athology  cf,  28 
l)alanitis,  92 

diagnosis  of,  94 
cervicitis,  551 
chronic  urethritis,  304 

treatment  cf,  304 
condylomata,  204 
citididymilis,  155 
urethritis,  urethroscopy  of,  665 
Syringe,   .lanet -Frank,   in   treatment  of 
urethritis,  til 
Keyes-l'ltzmann,  295 
Pedersen's,  in  treatment  of  urethri- 
tis, 61 
technic  of  use  of,  in  urethritis,  61-64 
Syringe-sound,  Bangs',  295 


Texorynovitis,  gonococcal,  248 

Test  -  glass,    multiple,    in    diagnosis    of 

urethritis,  41,  43 
Testicle,     state     of,     after     epidid\-mo- 

orchitis,  152 
Testis,   strapping  of,   in   acute  epididy- 
mitis, 160 
undescended,  ej)ididymitis  in,  153 
Thermophores,  use  of,  in  treatment  of 

urethritis,  502 
Thrombosis,  gonococcal,  225 
Tobacco  in  gonorrhea,  496 
Toxemia,    gonococcal,   225.     See   Septi- 
cemia and  bacteremia. 
Toxic  painless  hemorrhage  from  kidney, 

930 
Trachelectomy,   in   gonococcal   metritis, 

572 
Traumatic  acute  urethritis,  diagnosis  of, 
46 
etiology  of,  20 
affections  of  bladder,  806 


Traumatii-  chronic  urethritis,  263,  305 
treat n.ent  of,  306 
hemorrhage  from  kidney,  935 
hyilrocele,  acute,  153 
orchitis,  1.53 

strictiuv  of  luvthra,  341,  354 
ulcers  of  bladder,  773 
Traumatism  as  cause  of  urethritis,  20 
Treatment,  general  jjrinciples  of,  483 
Trei)onema  pallidum,  20,  22,  29,  38,  45, 

46 
Trigone,  simjjle  edema  of,  759 
Trigonitis,  chrome,  767 
'i'ulial  ])regnancy.  diagnosis  of,  587 
Tuberculosis  of  liladder,  SOS 
innnunization  in.  522 

coni])ared  with  gonorrhea,  523 
of  kidney,  SSI 

l)acteriol()gy  of,  891 
definition  of,  SSI 
diagnosis  of,  891  . 
dilTereiitiation  of,  891 
etiology  (  f,  ,881 
functional  renal  tests  in,  890 
occurrence  of,  881 
radiogra])hy  in,  890 
symptoriis  of,  objective,  886 

subjective,  881 
treatment  of,  892 
ureteral  catheterization  in,  888 
urinalysis  in,  889 
Tuberculous  cervicitis,  552 
cystitis,  767 

cystoscopic  pictures  of,  769 
definition  of,  7()7 
differential  diagnosis  of,  770 
focal  .sym])toms  of,  767 
pathology  of,  768 
urinalysis  of,  7()7 
epididymitis,  155,  157 
prostatitis.  957 
.si)ermatccystitis,  diagnosis  of,  131 

treatment  of.  132 
urethritis,  urethroscopy  of,  662 
Tubular  cystoscoiie,  704 
Tumors,  ovarian,  diagnosis  of,  586 

of  tubes,  sohd,  diagnosis  of,  .587 
Turbidity  tests  of  urine,  170 
in  cystitis,  170 
Two-journej'  plan.  368 
Typhoid  ulcers  of  bladder,  774 


Ulceration  of  bladder.  773 

cancerous,  775 

definition  of,  773 

simple.  S07 

solitary,  of  I'cnwick,  774 

traumatic,  773 

typhoid.  774 
Ulcers  of  posterior  urethra,  655 
Unilateral  kidney,  939 
I'nivcrsal  colorimeter,  856 
cystoscope,  704 


INDEX 


985 


Urates  in  ui'iiiai'y  scdiincnt:,  4()7,  4(jS 
Urea,  amount,  of,  in  blood,  HiVi 
Ureter,  almorinaiitics  of,  S1!J 

anatomical,  Si;'> 
ascendiiif^  infection  of,  ISO 
calculi  of,  S30 

chemical  composition  of,  KM 

cystoscopy  of,  838 

diagnosis  of,  837 

impacited,  836 

migratory,  83(i 

setjuels  of,  837 

treatment  of,  839 

ureteral  catheterization  in,  839 
dilatation  of,  835.     »S'ee  Obstruction 

of. 
fistula  of,  840.     See  Ureter,  wounds 

of. 
multiple,  939 
normal,  812 

anatomy  of,  812 

physiology  of,  813 
obstruction  of,  835 

causes  of,  835 

clinical  features  of,  835 

inflammatory,  836 

lithic,  836 

mechanical,  835 

treatment  of,  836 
orifices  of,  761 
stricture  of,  834 

diagnosis  of,  835 

etiology  of,  834 

pathology  of,  834 

sequels  of,  834 

treatment  of,  835 
wounds  of,  840 

cystoscopy  in,  840 

diagnosis  of,  840 

occurrence  of,  840 

treatment  of,  840 

ureteral  catheterization  in,  840 
Ureteral  catheterization,  821 

aids  to,  828 

armamentarium  for,  821 

axial  vision  cystoscopy  in,    832 

bleeding  in  course  of,   827 

Braasch's  cystoscope  in,  833 

in  calculi  of  ureter,  839 

choice  of  catheters  for,  821 
of  instruments  in,  833 

conditions    diagnosticated    by, 
826 

cystoscopy  in,  828 

dangers  and  accidents  of,  827 

Eisner's  cystoscope  in,  833 

general  considerations,  821 

in  hydronephrosis,  898 

Kelly's  apparatusin,  832 

laterovision  cystoscopy  in,  832 

leakage  in,  828 

obstructions  in,  827 

specimens  secured  by,  825 

technic  of,  828 

traumatism  due  to,  827 

in  tuberculosis  of  kidney,  888 


Ureter!!,!  ctiJhcf.crization,  urine  of,  825 

withdrawal  of  catlietrjrs  in,  825 
in  wounds  of  uniter,  840 
x-ray  cathfiters  for,  823 
meatus,  pathological,  818 
diagnosis  f)f,  819 
Ureteritis,  177 

acutf!,  diagnosis  of,  183 
asctsnding,  180 
Jiacillus  coli  as  cause  of,  177 
chronic,  329 

diagnosis  of,  183 
definition  of,  177 
diagnosis  of,  183 
descending,  182 
etiology  of,  178 
gonococcal  acute,  treatment  of,  188 

chronic,  treatment  of,  188 
gonococcus  as  cause  of,  178 
occurrence  of,  177 
pathology  of,  179 
primary,  179 
secondary,  179 
symptoms  of,  180 
termination  of,  182 
varieties  of,  178 
Ureteropyelitis,  178 

Ureteropyelonephritis,  electrotherap}'  of, 
188 
hydrotherapy  of,  188 
local  measures  against,  189 
medication  in,  189 
phototherapy  of,  188 
prophylaxis  of,  188 
serotherapy  of,  189 
surgery  of,  189 
treatment  of,  curative,  188 
Ureters,  812 

supernumerary,  815 
Urethra,  anatomy  of,  17 
gross.  17 
minute,  17 
anterior,  269 

false  passage  in,  658 

urethroscopic,    diag- 
nosis of,  658 
treatment  of,  658 
urethroscopic  lesion  of,  657 
bacteriology  of,  469 
bulb  of,  anatomy  of,  435 
calcuh  of,  uretlu-oscopy  of,  675 
caliber  of,  342 

carcinoma  of,  urethroscopj'  of,  672 
chancre  of,  28,  304 
chancroid  of,  20,  30,  304 
discharge  from,  444 

bacteriolog}-  of,  446-450 
examination-technic  of,  444 
varieties  of.  444 

balanoposthitic,  445 
false  passage  in,  409 

compUcations  of.  412 
definition  of.  409 
diagnosis  of,  411 
etiology  of,  410 
pathology  of,  410 


986 


INDEX 


Urethra,  false  passage  in,  symptoms  of, 
410 
treatment  of,  412 

cystoscopic,  656,  658 
varieties  of,  409 
female,  calculi  of,  urethroscopy  of, 
tiSO 
carcint)nia  of,  urethroscopy  of, 

t)79 
{jonococcal  lesions  of,  678 
method    of    (.)btaining    smears 

from,  481 
neoplasms  of,  urethroscopy  of, 

()71) 
nonjionococcal  lesions  of,  678 
l)apilIoma  of,  urethroscopy  of, 

679 
polypi  of,  urethroscoi)y  of,  679 
sarcoma,  luethroscopy  of,  680 
segments  of,  677 
varices  of,  urethroscopy  of,  679 
filiform,  uretliroscopy  of,  667 
flora  of,  469 
follicular  cj'sts  of,  urethroscopy  of, 

667 
hemorrhage  from,  407 
diagnosis  of,  408 
etiology  of,  407 
significance  of,  407 
symptoms  of,  408 
treatment  of,  409 
internal  examination  of,  346 
irrigation  of,  drapery  of  patient  in, 
65 
Wolbarst  basin  in,  66 
membranous,   urethroscopic  lesions 
of,  657 
urethroscopy  of,  641 
normal  flora  of,  21 

segments  of,  640 
papillomata  of,  urethroscopy  of,  669 
penile,  urethroscopy  of,  641 
posterior,  269 

bullous  edema  of,  652 
exfoliations  of,  655 
granulations  in,  654 
infected  glands  of,  652 

treatment  of,  653 
polji^oid  masses  in,  655 
soft  infiltrations  in,  651 

treatment  of,  651 
thick  discharge  from,  653 
ulcers  of,  655 
urethroscopy  of,  647 
prostatic,    disease    of,    cystoscopic 
treatment  of,  656 
urethroscopy  of,  640 
resection  of,  407 

sarcoma  of,  urethroscopy  of,  674 
stricture  of,  334 
acquired,  338 
chronology  of,  341 
close,  347 

compHcations  and  sequelae     of, 
418 
diagnosis  of,  420 


Urethra,  stricture  of,  coinplications  and 
seciuehe    of,    dilTer- 
entiation  of,  420 
etiology  of,  419 
jiatliology  of,  420 
symptoms  of,  420 
treatment  of,  421 
congenital,  33S 

cystitis  following  treatment  of, 
"416 
delinition  of,  334 
diagnosis  of,  353 

tliiTerential,  356 
with  rectal  touch,  348 
witli  urethroineter,  356 
with  uri'tlu'os('oj)e,  348 
dilatation  of,  continuous,  383 
due  to  external  pressure,  341, 

350 
edematous,  341,  349 
electrolysis  of,  384 

aftertreatment  of,  387 
cases  suited  for,  385 
d'Arsonyal,  387 
galvanic,  386 
instnmicnts  for,  386 
technie  of,  386 
ei)ididyuiitis    following     treat- 
ment of,  416 
etiology  of,  334 
in  female,  599 

sj'^mptoms  of,  599 
treatment  of,  599 
gonococcal,  differentiation  from 
inflammatory,  356 
from  iK'riurethral,  357 
from  spasmodic,  357 
from  traumatic,  357 
inflammatory,  340,  349 
organic,  338,  343 

symptoms  of,  343 
pathology  of,  336 
prevention  of,  358 
prostatitis  following  treatment 

of,  416 
relapse  of,  352 
resection  for,  407 
retention    of    urine    following 

treatment  of,  421 
significance  of,  358 
spasmodic,  341,  349 
termination  of,  351 
tight,  347 

dilatation  of,  379 

with  filiforms,  380 
with  irrigating  sounds, 

379 
with     nonirrigating 
soimds,  382 
»      with  soft  instruments, 
382 
traumatic,  341,  350 
treatment  of,  362 
accidents  of,  407 
immediate,  362 
methods  of,  362 


INDEX 


987 


Urethra,     stricture    of,     trcatiruait    of, 
operative,  1388 
with  cystoscope,  656 
urethrifi.s   following   treatment 

of,  41f) 
urethrotomy,  external  for,  395 

internal  for,  388 
use  of  metal  dilators  in,  377 
of  soft  dilators  in,  377 
syphilis  of,  304 

varicosities  of,  urethroscopy  of,  671 
Urethral  caruncle,  268 
electrodes,  502 
folliculitis,   chronic,   312 
glands,  chronic  inflammation  of,  267 
polypi,  269 

urethroscopy  of,  670 
Urethritis,  acute,  17 

antiblennorrhagics  in,  503 
ardor  urinse  in,  40 
bacteriology  of,  21 
complications  and  sequelae  of, 
82 
circulatory,  223 
cutaneous,   201 

diagnosis  of,   201 
occurrence  of,  201 
treatment  of,  201 
digestive,  208 
locomotory,  247 
nervous,  238 
ocular,  240 
respiratory,  237 
sexual,  116 
urinary,  163 

etiology  of,  163 
prophylaxis  of,  163 
significance  of,  162 
definition  of,  17 
diagnosis  of,  42 
duration  of,  42 
establishment  of,  35 
etiology  of,  19 
extension  of,  18 

general  clinical  features  of,  34 
incubation  of,  35 
invasion  of,  35 
location  of,  18 
pathology  of,  27 
point  of  onset  of,  33 
relapses  in,  42 
stages  of,  35 
streptobacillary,  24 
symptoms  of,  33 
local,  34 
objective,  34 
subjective,  34 
systemic,  34 
termination  of,  35 
treatment  of,  medicinal,  503 
urinary  disturbances  in,  57 
varieties  of,  18,  19 
anterior,  comphcations  of,  511 
extragenital,  511 
urogenital,  511 
catarrhal  acute,  bacteriology  of,  22 


Urctliritis,  catarrhal  acute,  diagno.si.s  of, 
43 
etiology  of,  20 
pathology  of,  28 
symptoms  of,  36 
\irethroscopic  diagnosis  of, 
661 
treatment  of,  fi61 
catheterization  in,  506 
chancroidal  acutf;,  diagnosis  of,  45 
etiology  of,  20 
pathology  of,  30 
chronic,  304 

treatment  of,  304 
urethroscopy  of,  664 
chancrous,  chronic,  304 
in  childhood,  426 
chronic,  263 

aftertreatment  of,  286 
anterior,  269 

discharge  of,  270 
symptoms  of,  269 
antiblcnorrhagics  in,  504 
antiseptics  in,  504 
astringents  in,  504 
bacterial,  264 
comphcations  of,  307 
definition  of,  307 
general  chnical  features  of, 
307 
considerations  of,  307 
sequelge  of,  307 
varieties  of,  308 
definition  of,  263 
diagnosis  of,  331 
dilatation  in,  287 
electrotherapy  of,  278-281 
etiology  of,  330,  645 
hydrotherapy  of,  276 
instillation  in,  282 
irrigation  in,  282,  286 
mechanotherapy  of,  274 
medication  in,  281 
nongonococcal,  264 
occurrence  of,  329 
phototherapy  of,  277 
posterior,  diagnosis  of,  273 
discharge  of,  272 
sj^mptoms  of,  272 
treatment  of,  273 
abortive,  273 
curative,  274 
expectant,  274 
preventive,  273 
serotherapy  of,  282 
surgery  of,  283 
symptoms  of,  330 
traumatic,  263 
treatment  of,  274,  331 

medicinal,  504 
urethroscopy  in  diagnosis  of,  285 
complications  of,  treatment  of,  510 
cure  in,  tests  of,  286 
diagnosis  of,  laboratory,  445 
diathetic,  302 
acute,  302 


988 


INDEX 


rrctliritis.  liiatlietic  anterior,  ;>()J 
ehronic,  302 
liosterior,  302 
tn-atiiuMit  of,  302 
in  cpiiliilyniitis,  troatnient  of,  KU) 
eniptivo  acute,  jjathology  of,  28 
foUowinjj;  treatment  of  strieture,  416 
diajinosis  of,  417 
etiology  of,  41(1 
treatment  of,  418 
in  female,  521) 

gonococcal,  531 

aftertrcatment  of,  535 
cln\)nic,  534 
cure  of,  535 
diajiuoBis  of,  532 
met! i cat  ion  in,  534 
surjicry  of,  534    . 
symptoms  of,  531 
treatment  of,  533 
nongonococcal,  529 
gonococcal  acute,  21 

aftertrcatment  of,  70 
anterior,  complications  of, 
82 
symptoms  of,  39 
treatment    of,    con- 
servative, 53 
varieties  of,  82 
bacteriology  of,  24 
clinical  varieties,  38 
comjilications    of,    scro- 

ther;i]iy  of,  520 
cure  of,  tests  of,  73 
diagnosis  of,  4(i 
etiology  of,  21 
glanchdar  comijlications  of, 

106 
management  of,  47,  55 
pathology  of,  31 
l)osterior,  74 

coni])lications    of,    75, 

115,  201 
etiology  of,  74 
retention  of  urine  in, 

78 
significance  of,  74 
stages  of,  76 
symptoms,  74 
termination  of,  75 
treatment  of,  75-81 
prophylaxis  of,  47 
terminal  stage  of,  69 

treatment  of,  69 
treatment  of,  47 
abortive,  47-52 

Ballenger's  meth- 
od, 49 
by    instillation 
and  retention 
method,  49 
bj'  irrigation,  48 
by  Janet's  meth- 
od, 49 
conservative,  53-55 
curative,  52-56 


livthritis,  gonococcal  acute,  treatment 
of,     irrigation,     64, 
70,  79 
local,  60 
systemic,  59 
with  injections,  61 
cliromC,  2(i4 

anterior,  2t)4,  269 

discharge  of,  270 
sym])toms  of,  269 
complications    of,    sero- 
therapy of,  520 
etiology  of,  2(54 
granulomata  in,  268 
occurrence  of,  264 
l)a])illomata  in,  268 
pathologv  of,  33,  265 
posterior,  264,  2()8,  288 
cure  of,  301 
diagnosis  of,  291 
electrotherapy  of,  290, 

293 
hydrotherapy  of,  292 
instrumentation  in,294 
meclianotherapv     of, 

229 
medication  in,  294 
symptoms  of,  288 
treatment  of,  289,  291 
jirogressive,  266 
significance  of,  264 
stationary,  266 
symptoms  of,  269 
comjilications    of,    serothcrapv 

of,  520 
in  female,  598 

uncomplicated,-  serotherap.y  of, 
519 
herpetic  acute,  pathology  of,  30 
symptoms  of,  38 
urethroscoi:)y  of,  661 
injections  in,  508 
instillation  in,  507 
irrigation  in,  507 
masked  discharge  of,  449 
neo})lastic,  urethroscopy  of,  677 
nonbacterial   nongonococcal    acute, 

symptoms  of,  36 
nongonococcal   acute,   bacterial,   22 
bacteriology  of,  21 
complications  of,  260 
classification  of,  260 
cure  of,  262 
.significance  of,  260 
treatment  of,  261 
diagnosis  of,  43 
etiology  of,  19 
nonbacterial,  21 
pathology  of,  27 
symptoms  of,  36 
chronic,  301 

treatment  of,  301 
treatment  of,  81 
urethrosco[)ic  lesions  of,  659 
diverticula  of,  659 
significance  of,  659 


INDEX 


989 


Urethritis,  n()nj2;()n()f()('("il  ii(uii(^,  urcithro- 
sciopic  lesions  of,  viilvcs  oi',  (if)!) 
in  old  agc!,  427 

posterior,   (lif'forentitition  from  cys- 
titis, 172 
pyogenic,  28,  303 
acute,  303 

diagnosis  of,  44 
symptoms  of,  37 
anterior,  ;}()3 
chronic,  303 
cocci  as  causes  of,  177 
posterior,  'MYi 
treatment  of,  303 
retrojection  in,  507 
suppurative,  urethroscopy  of,  661 
syphihtic  acute,  bacteriology  of,  22 
diagnosis  of,  45 
etiology  of,  20 
pathology  of,  28 
chronic,  304 

treatment  of,  304 
urethroscopy  of,  665 . 
traumatic  acute,  diagnosis  of,  46 
etiology  of,  20 
chronic,  305 

of  caustic  origin,  306 
treatment  of,  305 
tuberculous,  urethroscopy  of,  662 
use  of  sounds  in,  508 
Urethrocystitis.     See  also  Cystitis, 
electrotherapy  of,  174 
gonococcal  acute,  163 

definition  of,  165 
diagnosis  of,  165 
pathology  of,  164 
symptoms  of,  164 
termination  of,  164 
treatment  of,  166,  173 
varieties  of,  164 
chronic,  327 

diagnosis  of,  328 
symptoms  of,  327 
treatment  of,  173,  328 
local  management  of,  174 
medication  in,  174 
operations  for,  175 
phototherapy  of,  174 
serotherapy  of,  174 
surgery  of,  175 
Urethrocystoscope  in  ureteral  catheteri- 
zation, 832 
Urethrometer  in  diagnosis  of  stricture, 

356 
Urethroscope,  care  of,  627 

in  diagnosis  of  stricture,  348 
field  of,  638 

introduction  of,  630-634 
curved  tip,  634 
straight  tip,  631 
lateral  fenestrum  type,  642 
meatal,  616 

optical  principles  of,  617 
sterilization  of,  627 
terminal  fenestrum  type,  639- 
tj^pes  of,  617 


Ureihroscoix:  with  (extrinsic  illiiminMtion, 
fil7 
with  water  dilatation,  622 
(Jretliroscopic  internal  urr;throtomy,  303 
Urethroscopy,  616 

anesthetics  for,  627 
basis  of  sucf;ess  in,  624 
of  calculi  of  urcithra,  675 

in  female,  (iSO 
of  carcinoma  of  lu'ethra,  672 

in  fernal(!,  679 
of  catarrhal  urtithritis,  661 
of  chancroidal  unithritis,  664 
complete,  647 
contraindications  of,  f)2() 
in  diagnosis  of  urethritis,  285 
of  female,  676 

instruments  for,  676 
technic  of,  677 
of  filiform  urethra,  667 
of  follicular  cysts  of  urethra,  667 
gonococcal  lesions  of,  643 

attachment  of,  643 

color  of,  643 

elasticity  of,  644 

folds  of,  644 

glands  of,  644 

gloss  of,  644 

thickness  of,  643 

vascularity  of,  643 
of  herpetic  urethritis,  661 
indications  for,  625 
in  male,  616 

of  membranous  urethra,  641 
of  neoplastic  urethritis,  667 

in  female,  679 
of  normal  urethra,  634 

clinical  features  of,  637 
of  papilloma  of  urethra,  669 

in  female,  679 
pathological  features  of,  643 
of  penile  urethra,  641 
of  polypi  of  urethra,  670 

in  female,  679 
of  posterior  urethra,  647 
preparation  for,  628 
of  equipment,  629 
of  patient,  629 
of  room,  629 
of  prostatic  urethra,  640 
record  chart  for,  635 
of  sarcoma  of  urethra,  674 

in  female,  680 
styptics  for,  627 
of  suppurative  urethritis,  661 
of  s\T)hiLitic  urethritis,  665 
technic  of,  628 
therapeutic,  680 

of  gonococcal  lesions,  680 

management  of,  680 
methods  of,  681 
of  nongonococcal  lesions,  681 
of  tuberculous  urethritis,  662 
of  utricular  cyst  of  prostate,  666 
of  varicosities  of  urethra,  671 

in  female,  679 


990 


IXDEX 


Urethroswpy  of  vosioal  neck,  MO 
Urethrotomy  in  cystitis,  17ti 
external,  395 

nftertreatment  of.  399-401 

cases  suited  for,  395 

instruments  for,  396 

preparation  of  patient,  for,  390 

Sinclair  type,  403 

varieties  of,  39t) 

W'liet'lliouse  type'  401 

witli  cystotomy,  402 

witli  ^uide,  39(> 

witli  metal  staff,  39l>-399 

with  whalebone  fiuide,  399 

without  a  Kuide,  401 
internal,  388,  390 

aftertreatmcnt  of,  394 

anterior,  391 

cases  suited  for,  390 

incision  in,  394 

instruments  for,  390,  394 

Maisonneuvc's,  393 

Otis's,  391 

Oudin's  current  in,  394 

posterior,  393 

jjreparation  of  patient  for,  390 

urethroscopic,  393 

varieties  of,  391 
Uric  acid,  467 

amount  of,  in  blood,  864 
Urinalysis,  457 

in  cystosco])y,  690 
dcfmition  of,  457 
in  hydronephrosis,  898 
in  renal  tumors,  907 
in  tuberculosis  of  kidney,  889 
in  tuberculous  cj'stitis,  767 
Urinary  antiseptics  in  treatment  of  acute 
urethritis,  60 
crystals,  466 

ammonium  urate,  467 

calcium  oxalate,  467 

triple  phosphates,  468 

uric  acid,  467 
disturbances  in  acute  urethritis,  57 
infection,  412 

definition  of,  412 

diagnosis  of,  414 

etiology  of,  412 

pathology  of,  413 

symptoms  of,  413 

synonyms  of,  412 

treatment  of,  415 
sediment,  amorphous,  466 

bacterial,  469 

blood  cells  in,  459 

brick  dust,  467 

calcium  oxalate,  467 

casts  in,  463 

crj'stallinc,  466 

epithelia  in,  461 

parasitic,  469 

phosphates,  468 

amorphous,  468 
cr>-stalUne,  468 

pus  ceils  in,  460 


Urinary  sediment,  urates,  467,  468 
uric  acid,  467 
varieties  of,  467 
Urine,  Bacillus  coli  communis  in,  471 
tuberculosis  in,  472 
characters  of,  chemical,  458 
elements  of,  458 
microscopic,  459 
physical,  458 
cryosc()i)y  of,  846 
extravasation  of,  421 
diagnosis  of,  425 
etiology  of,  421 
iiiciiii)ranous,  424 
IKithology  of,  422 
])enil(>,  424 
prophylaxis  of,  425 
prostatic,  424 
symptoms  of,  424 
synonyms  of,  421 
treatment  of,  425 
gonococcus  in,  470 

demonstration  of,  474 
neutralization  of  acid,  57 

in  treatment  of  urethritis,  57 
parasites  of,  470 

noni)athogenic,  470 
pathogenic,  471 
pyogenic  organisms  in,  471 
retention  of,  acute,  197 

aftertreatmcnt  of,  200 
cure  in,  evidence  of,  200 
definition  of,  197 
diagnosis  of,  198 
in  epididymitis,  160 
etiology  of,  197 
gonococcal,  198 
hydrotherapy  in,  198 
medication  in,  199 
phototherapy  of,  199 
j)roi)hylaxis  of,  198 
in  prostatitis,  125 
symptoms  of,  197 
treatment  of,  198 
curative,  198 
local,  199 
operative,  199 
varieties  of,  197 
chronic,  331 

cure  of,  332 
definition  of,  331 
diagnosis  of,  331 
etiology  of,  331 
occurrence  of,  331 
symptoms  of,  331 
treatment  of,  331 
following    treatment    of    stric- 
ture, 421 
in  posterior  urethritis,  78 
in  spermatocystitis,  136 
staphylococcus  in,  471 
streptococcus  in,  471 
turbidity  tests  of,  170 
of  ureteral  catheterization,  825 
Urogenital  system,  female,  anatomy  of, 
524 


INDEX 


991 


Urogenital  system,  female,  anatomy  of, 
gross,  524 
minute,  525 
infections  of,  525 
Uterine   appendages,    gonococcal   infec- 
tion of,  577 
acute,  580 
chronic,  582,  590 
cure  of,  590 
curettage  in,  592 
definition  of,  577 
diagnosis  of,  584 

differential,  585 
etiology  of,  577 
hydrotherapy  of,  588 
medication  in,  588 
oophorectomy  in,  594 
pathology  of,  578 
relapsing,  583 
salpingectomy  in,  592 
surgery  of,  589,  591 
conservative,  595 
radickl,  596 
symptoms  of,  580 
synonyms  of,  577 
treatment  of,  588 
type  of,  577 
uterine  surgery  in,  595 
varieties  of,  577 
Uterus,  abscess  of,  gonococcic,  610 

conservative  surgery    of,    in    gono- 
coccal infection,  595 
Utricular  cysts  of  prostate,  urethroscopy 
of,  666 


Vaccine,  gonococcal,  513 

Vagina,  mode    of    obtaining    specimens 

from,  481 
Vaginaiitis.     See  Hydrocele. 
Vaginitis,  gonococcal,  538 

aftertreatment  of,  546 
cure  of,  546 
diagnosis  of,  540 

differential,  541 
hydrotherapy  of,  543 
medication  in,  545 
pathology  of,  538 
significance  of,  538 
surgery  of,  546 
symptoms  of,  539 
treatment  of,  542 
abortive,  543    . 
curative,  543 
varieties  of,  538 
Van  Cott's  combined  bacterin,  514 
Varicose  painless  hemorrhage  from  kid- 
ney, 931 
Varicosities  of  urethra,  urethroscopy  of, 
671 
in  female,  679 
Varix,  renal.     See  Kidney,  varix  of. 
Vascular  lesions,  gonococcal,  224-225    . 
Vasostomy,  138 
Venereal  warts,  202 


Vesicle,  seminal,  abscess  of,  130 
anatomy  of,  441 
examination-technic  of,  442 
pathology  of,  442 
Vesiculitis,  seminal,    126.     See  .Sperma- 

tocystitis. 
Vesiculotomy,  138-146 
Vulva,  pruritus  of,  gonococcal,  603 

treatment  of,  ()03 
Vulvitis,  gonococcal,  535 
acute,  536 

aftertreatment  of,  538 
chronic,  536 
cure  of,  538 
diagnosis  of,  536 
hydrotherapy  of,  537 
medication  in,  537 
surgery  of,  538 
symptoms  of,  535 
treatment  of,  536 
Vulvovaginal  glands,  gonococcal  inflam- 
mation of,  603 
acute,  605 

aftertreatment  of,  610 
chronic,  606 
cure  of,  610 
cystic,  606 
diagnosis  of,  606 
differentiation  of,  607 
medication  in,  609 
pathology  of,  604 
surgery  of,  609 
symptoms  of,  604 
treatment  of,  608 
obtaining  specimens  from,  481 


W 


Warts,  neoplastic,  205 

differentiation    from    venereal 
warts,  205 
venereal,  202 

in  rectal  gonorrhea,  211 
Wassermann  blood  test  in  diagnosis  of 

urethritis,  43-46 
Waxy  casts  in  urine,  465 
Wheelhouse,    external   urethrotomy    of, 

401 
Wolbarst's  five-glass  test,  271,  452 

Pedersen's  modifica- 
tion of,  453 
Wounds  of  ureter,  840 

cystoscopy  of,  840 

diagnosis  of,  840 

treatment  of,  840 

ureteral  catheterization  in,  840 


Young's  method  of  obtaining  prostatic 
secretion,  317 
multiple  glass  test,  456 
ointment  sound.  295 
prostatic  punch,  963 
summary  on  prostatic  secretion,  317 


on  T  LIBHAHIE8 

il,'"'''    '"''■' 


0052843599 


DATE  DUE 


Demco,  Inc.  38 


